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									                                                                                     April 2009

Ancillary Common Fee Schedule
Tips from Blue Cross and Blue Shield of Florida

The following information applies to ancillary providers with participation agreements that
designate the Ancillary Common Fee Schedule (ACFS) as the contractual fee schedule. These
participation agreements will generally have an exhibit titled “Ancillary Base Fee Schedule.”

The number designation (code) for any of the codes listed in the ACFS are subject to
modification (including addition, deletion, or combination of codes) as a consequence of
periodic, published changes by Blue Cross and Blue Shield of Florida, Inc. (BCBSF), the
American Medical Association (AMA), the Centers for Medicare & Medicaid Services (CMS), or
other nationally recognized sources. In the event that CPT-4/HCPCS codes are modified by a
published change, a listing of each of the new and/or modified codes, and the corresponding
base allowances will be supplied via BCBSF’s website, www.bcbsfl.com, no later than thirty (30)
days after implementation.

In accordance with the terms of the applicable participation agreement, allowances may be
calculated by multiplying the negotiated contract rate(s) by the ACFS allowance for the specific
procedure. The calculation formula is: A x B = C or, Base Fee Schedule Allowance (A) x
Contract Rate (B) = Negotiated Contract Allowance (C)

For additional information about BCBSF’s ACFS contact the Network Management Service Unit
at (800) 727-2227, say “More Choices,” then “Network Management.”

Note: The ACFS is subject to the terms and conditions of the applicable participation
agreement, including established medical coverage guidelines, bundling guidelines, coding
edits, and pricing rules. Reimbursement for covered services is determined by the member’s
benefits that are applied to the negotiated contract allowance.

April 2009 Revisions
Since the November 2008 online posting, the bolded codes have been added or modified.
The following provider types include revisions as noted:

•   Durable Medical Equipment (DME pages 1-4, 9, 11, 15, 18 and 25)
•   Independent Clinical Laboratory (ICL pages 3-5, 8 and 9)
•   Independent Diagnostic Testing Center (IDTC pages 4 and 6)

You may use the bookmarks to quickly access a specific provider type or validate the month and
year each was updated (e.g., 1108 for November 2008, 0409 for April 2009).



900-1101-0409
                               Ambulance
      Code       Allowance
      A0225         1,445.03
      A0130            67.50
      A0160             0.50
      A0425             8.13
      A0426           298.30
      A0427           472.32
      A0428           248.59
      A0429           397.74
      A0430         4,067.58
      A0431         4,729.15
      A0433           683.61
      A0434           807.91
      A0435            19.47
      A0436            51.90
      A0999             0.00
      J3490       ASP + 6%
    Average Sale Price (ASP)




900-1101-1108                     A-1      www.bcbsfl.com
                             Behavioral Health
  Code          Allowance
  90801             146.39
  90802             193.80
  90804              63.01
  90806              94.41
  90808             140.89
  90810              68.41
  90812             101.60
  90814             147.34
  90816              63.31
  90818              95.10
  90821             141.56
  90823              67.93
  90826             101.23
  90828             147.27
  90846              91.51
  90847             111.94
  90849              32.30
  90853              30.76
  90857              33.64
  90875              78.54
  90876             113.56
  90880             119.34
  90882              99.59
  90885              49.36
  90887              85.47
  90889              85.29
  96103              27.14
  97532              25.43
  97533              25.11
  97537              26.20
  99406              12.13
  99407              23.26
  99408              28.23
  99409              55.91




900-1101-1108                       BH - 1       www.bcbsfl.com
                            Birthing Center
       Birthing             Diagnostic Services
  Code       Allowance      Code       Allowance
  59400         4,063.35    76805           176.36
  59425           916.47
  59426         1,718.60
  59430           377.75
  J2790       ASP + 6%
 Average Sale Price (ASP)




900-1101-1108                          BC - 1        www.bcbsfl.com
                             Durable Medical Equipment
          Bone Growth Stimulators                              Entral Formula and
       Code      Modifier   Allowance                           Medical Supplies
       E0747       NU            4,946.38                Code       Modifier    Allowance
       E0747       RR              491.53                B4034         NU               8.02
       E0748       NU            4,914.33                B4035         NU              15.29
       E0748       RR              491.43                B4036         NU              10.49
       E0749       NU            3,197.12                B4081         NU              27.23
       E0749       RR              377.90                B4082         NU              19.28
       E0760       NU            4,083.71                B4083         NU               3.23
       E0760       RR              408.38                B4103         NU               0.00
       E0770       NU                0.00                B4104         NU               0.00
                                                         B4149         NU               1.90
         Diabetic Pump and Supplies                      B4150         NU               0.88
       Code        Modifier  Allowance                   B4152         NU               0.73
       A4230         NU             14.89                B4153         NU               2.50
       A4231         NU              5.44                B4154         NU               1.45
       A4232         NU              5.09                B4155         NU               1.24
       E0784         NU          7,262.50                B4157         NU               6.79
       E0784         RR            726.25                B4158         NU               2.11
       K0552         NU              2.74                B4159         NU               4.31
       K0601         NU              1.15                B4160         NU               0.65
       K0602         NU              6.66                B4161         NU               5.41
       K0603         NU              0.60                B4162         NU              24.38
       K0604         NU              6.38                B4164         NU              22.73
       K0605         NU             15.31                B4168         NU              31.48
                                                         B4172         NU              70.53
                Diabetic Supplies                        B4176         NU              60.91
       Code         Modifier    Allowance                B4178         NU              67.98
       A4206           NU               0.32             B4180         NU              32.61
       A4210           NU            544.56              B4189         NU             225.89
       A4233           NU               0.72             B4193         NU             296.69
       A4234           NU               3.28             B4197         NU             353.85
       A4235           NU               2.10             B4199         NU             362.84
       A4236           NU               1.52             B4216         NU               9.77
       A4245           NU               2.23             B4220         NU              10.17
       A4250           NU             13.04              B4222         NU              12.54
       A4253           NU             33.26              B4224         NU              30.24
       A4255           NU               3.51             B9000         NU           1,607.63
       A4256           NU               9.48             B9000         RR             147.73
       A4257           NU             11.46              B9002         NU           1,607.63
       A4258           NU             16.23              B9002         RR             155.71
       A4259           NU             10.84              B9004         NU           3,409.29
       E0607           NU             59.45              B9004         RR             507.66
       E0607           RR               5.94             B9006         NU           3,409.29
       E2100           NU            486.37              B9006         RR             507.66
       E2100           RR             48.64
       E2101           NU            167.75
       E2101           RR             16.78
       J1815           02         AWP - 20%
       J1817           02         AWP - 20%
       J1817           NU          ASP + 6%
       S8490           NU             19.13
   Average Sale/Wholesale Price (ASP/AWP)


900-1101-0409                                  DME - 1                                    www.bcbsfl.com
                           Durable Medical Equipment
                General                                     General
       Code     Modifier    Allowance               Code    Modifier   Allowance
       A4601      NU               0.00             E0202     RR              69.04
       A4601      RR               0.00             E0205     NU             213.97
       A6441      NU               0.88             E0205     RR              23.53
       A6442      NU               0.22             E0205     UE             160.48
       A6444      NU               0.75             E0210     NU              35.99
       A6445      NU               0.43             E0210     RR               3.41
       A8000      NU             205.37             E0210     UE              26.99
       A8000      UE             154.03             E0215     NU              78.11
       A8001      NU             205.37             E0215     RR               8.17
       A8001      UE             154.03             E0215     UE              58.58
       A8002      NU               0.00             E0217     NU             547.42
       A8002      RR               0.00             E0217     RR              60.95
       A8002      UE               0.00             E0217     UE             410.57
       A8003      NU               0.00             E0218     NU             409.38
       A8003      UE               0.00             E0218     RR              47.41
       A8004      NU               0.00             E0218     UE             307.03
       A8004      UE               0.00             E0220     NU               9.34
       A9284      NU               0.00             E0220     RR               0.98
       E0184      NU             252.57             E0220     UE               7.01
       E0184      RR              31.88             E0221     NU           2,684.28
       E0184      UE             189.43             E0221     RR             268.42
       E0185      NU             385.71             E0225     NU             428.53
       E0185      RR              49.56             E0225     RR              42.24
       E0185      UE             289.28             E0225     UE             321.40
       E0186      NU             224.11             E0230     NU              11.00
       E0186      RR              26.33             E0230     RR               1.15
       E0187      NU             224.11             E0230     UE               8.25
       E0187      RR              26.33             E0235     NU             166.70
       E0188      NU              29.15             E0235     RR              22.38
       E0188      UE              21.86             E0236     NU             363.35
       E0189      NU              67.40             E0236     RR              48.78
       E0189      UE              50.55             E0236     UE             272.51
       E0191      NU              12.01             E0238     NU              29.81
       E0191      RR               1.19             E0238     RR               2.99
       E0191      UE               9.01             E0238     UE              22.36
       E0196      NU             358.69             E0239     NU             583.52
       E0196      RR              42.15             E0239     RR              58.36
       E0197      NU             244.32             E0239     UE             437.64
       E0197      RR              33.70             E0247     NU               0.00
       E0197      UE             183.24             E0247     RR               0.00
       E0198      NU             287.44             E0247     UE               0.00
       E0198      RR              29.77             E0249     NU             109.82
       E0198      UE             215.58             E0249     RR              12.08
       E0199      NU              39.91             E0249     UE              82.37
       E0199      RR               4.00             E0325     NU              11.56
       E0199      UE              29.93             E0325     RR               1.66
       E0200      NU              87.42             E0325     UE               8.67
       E0200      RR              11.87             E0326     NU              13.62
       E0200      UE              65.57             E0326     RR               1.55
       E0202      NU             514.05             E0326     UE              10.22


900-1101-0409                             DME - 2                                www.bcbsfl.com
                           Durable Medical Equipment
                General                                      General
       Code     Modifier    Allowance                Code    Modifier   Allowance
       E0370      NU               31.84             E0655     RR              13.98
       E0370      RR                3.20             E0655     UE             100.44
       E0487      NU                0.00             E0656     NU               0.00
       E0606      NU              215.28             E0656     RR               0.00
       E0606      RR               25.30             E0656     UE               0.00
       E0610      NU              308.55             E0657     NU               0.00
       E0610      RR               32.54             E0657     RR               0.00
       E0610      UE              231.41             E0657     UE               0.00
       E0615      NU              621.12             E0660     NU             176.94
       E0615      RR               75.43             E0660     RR              18.34
       E0615      UE              465.84             E0660     UE             132.71
       E0617      RR              394.42             E0665     NU             163.50
       E0618      NU            2,301.98             E0665     RR              16.34
       E0618      RR              309.12             E0665     UE             122.63
       E0619      NU            2,346.00             E0666     NU             179.12
       E0619      RR              435.83             E0666     RR              18.15
       E0620      NU            1,134.26             E0666     UE             134.34
       E0620      RR              113.41             E0667     NU             419.99
       E0620      UE              850.70             E0667     RR              47.43
       E0621      NU              110.04             E0667     UE             314.99
       E0621      RR               11.01             E0668     NU             573.21
       E0621      UE               82.53             E0668     RR              56.57
       E0627      NU              437.57             E0668     UE             429.91
       E0627      RR               43.77             E0669     NU             225.80
       E0627      UE              328.18             E0669     RR              22.59
       E0628      NU              437.57             E0669     UE             169.35
       E0628      RR               43.77             E0671     NU             538.79
       E0628      UE              328.18             E0671     RR              53.89
       E0629      NU              429.00             E0671     UE             404.09
       E0629      RR               42.92             E0672     NU             418.65
       E0629      UE              321.75             E0672     RR              41.87
       E0630      NU              836.69             E0672     UE             313.99
       E0630      RR              112.35             E0673     NU             347.87
       E0635      NU            1,004.78             E0673     RR              34.79
       E0635      RR              134.92             E0673     UE             260.90
       E0636      RR            1,358.27             E0675     NU           4,245.43
       E0637      NU            2,059.40             E0691     NU           1,165.64
       E0637      RR              196.76             E0691     RR             116.57
       E0638      NU            1,092.67             E0691     UE             874.23
       E0638      RR              109.27             E0692     NU           1,463.72
       E0650      NU              863.62             E0692     RR             146.36
       E0650      RR              106.43             E0692     UE           1,097.79
       E0650      UE              647.72             E0693     NU           1,804.38
       E0651      NU            1,191.37             E0693     RR             180.44
       E0651      RR              121.70             E0693     UE           1,353.29
       E0651      UE              893.53             E0694     NU           5,743.15
       E0652      NU            6,877.04             E0694     RR             574.31
       E0652      RR              679.66             E0694     UE           4,307.36
       E0652      UE            5,157.78             E0776     NU             185.71
       E0655      NU              133.92             E0776     RR              22.30


900-1101-0409                              DME - 3                                www.bcbsfl.com
                           Durable Medical Equipment
                General                                      General
       Code     Modifier    Allowance                Code    Modifier   Allowance
       E0776      UE              139.28             E1310     NU           2,367.76
       E0779      NU              169.91             E1310     RR             202.52
       E0779      RR               19.97             E1310     UE           1,775.82
       E0780      NU               13.46             E1340     NU              17.85
       E0781      NU            2,342.14             E1353     NU              86.46
       E0781      RR              314.52             E1353     RR               4.26
       E0782      RR              511.33             E1355     NU              58.77
       E0791      NU            2,967.22             E1372     NU             179.77
       E0791      RR              348.64             E1372     RR              26.12
       E0840      NU               95.05             E1372     UE             134.83
       E0840      RR               18.02             E1399     NU               0.00
       E0840      UE               71.29             E1510     NU           8,913.88
       E0849      NU              668.46             E1510     RR             389.67
       E0849      RR               66.83             E1520     NU             541.19
       E0849      UE              501.35             E1520     RR              61.12
       E0850      NU              136.29             E1530     NU             821.35
       E0850      RR               18.71             E1530     RR              86.60
       E0850      UE              102.22             E1540     NU             503.00
       E0855      NU              641.11             E1540     RR              53.49
       E0855      RR               64.13             E1560     NU             935.96
       E0855      UE              480.83             E1560     RR              98.05
       E0860      NU               48.44             E1570     NU             533.56
       E0860      RR                7.18             E1570     RR              73.86
       E0860      UE               36.33             E1580     NU           1,000.90
       E0900      NU              141.27             E1580     RR              73.86
       E0900      RR               30.50             E1590     NU           6,000.31
       E0900      UE              105.95             E1590     RR             250.86
       E0912      NU              701.73             E1592     NU           6,000.31
       E0912      RR              126.38             E1592     RR             261.04
       E0930      NU              504.42             E1594     NU           6,000.31
       E0930      RR               59.27             E1594     RR             261.04
       E0935      RR               29.49             E1610     NU           3,333.79
       E0940      NU              340.25             E1610     RR             333.63
       E0940      RR               39.98             E1615     NU           3,333.79
       E0941      NU              479.25             E1615     RR             333.63
       E0941      RR               56.32             E1620     NU             994.54
       E0942      NU               25.75             E1620     RR              99.33
       E0942      RR                2.77             E1625     NU             267.42
       E0942      UE               19.31             E1625     RR              26.74
       E0944      NU               50.59             E1632     NU           4,667.05
       E0944      RR                5.08             E1635     NU           4,667.05
       E0944      UE               37.94             E1636     NU             786.97
       E0945      NU               48.87             E1700     NU             447.33
       E0945      RR                4.89             E1700     RR              43.87
       E0945      UE               36.64             E1700     UE             335.50
       E0977      NU               72.12             E1701     NU              13.05
       E0977      RR                6.96             E1702     NU              26.25
       E1298      NU              487.71             E1800     NU           1,005.88
       E1298      RR               48.77             E1800     RR             135.07
       E1298      UE              365.78             E1802     RR             423.92


900-1101-0409                              DME - 4                                www.bcbsfl.com
                           Durable Medical Equipment
                General                                        General
       Code     Modifier    Allowance                Code      Modifier   Allowance
       E1805      NU            1,037.35             K0609       KF           1,017.85
       E1805      RR              139.31             K0609       NU           1,017.85
       E1806      RR              100.96             K0738       RR              42.05
       E1810      NU            1,022.86
       E1810      RR              137.37                     Hospital Beds
       E1812      NU            1,186.66             Code      Modifier    Allowance
       E1815      NU            1,037.35             E0100       NU               27.34
       E1815      RR              139.31             E0100       RR                5.58
       E1816      RR              129.89             E0105       NU               63.70
       E1818      RR              132.63             E0105       RR                8.31
       E1820      NU              106.04             E0110       NU               94.30
       E1820      RR               10.60             E0110       RR               15.87
       E1820      UE               79.53             E0111       NU               58.72
       E1821      NU              109.63             E0111       RR                7.92
       E1821      RR               10.95             E0112       NU               40.79
       E1821      UE               82.23             E0112       RR                9.32
       E1825      NU            1,037.35             E0113       NU               23.29
       E1825      RR              139.31             E0113       RR                4.83
       E1830      NU            1,037.35             E0114       NU               54.03
       E1830      RR              139.31             E0114       RR                8.03
       E1840      RR              378.31             E0116       NU               30.59
       E1841      RR              587.63             E0116       RR                5.06
       E2000      RR               61.52             E0117       NU              249.99
       E2120      RR              367.78             E0117       RR               24.98
       E2500      NU              507.29             E0130       NU               91.11
       E2500      RR               50.73             E0130       RR               18.57
       E2500      UE              380.47             E0135       NU              108.76
       E2502      NU            1,551.19             E0135       RR               19.06
       E2502      RR              155.13             E0140       NU              467.92
       E2502      UE            1,163.39             E0140       RR               46.81
       E2504      NU            2,046.22             E0141       NU              148.96
       E2504      RR              204.64             E0141       RR               24.69
       E2504      UE            1,534.67             E0143       NU              146.61
       E2506      NU            3,000.37             E0143       RR               23.83
       E2506      RR              300.03             E0193       NU            8,906.74
       E2506      UE            2,250.28             E0193       RR            1,046.54
       E2508      NU            4,639.57             E0194       NU           34,007.92
       E2508      RR              463.97             E0194       RR            3,723.72
       E2508      UE            3,479.68             E0194       UE           25,505.94
       E2510      NU            8,779.78             E0250       NU            1,079.27
       E2510      RR              877.97             E0250       RR              126.81
       E2510      UE            6,584.84             E0251       NU              817.84
       K0455      RR              306.15             E0251       RR               96.10
       K0606      RR            2,864.05             E0255       NU            1,239.57
       K0607      NU              245.25             E0255       RR              145.65
       K0607      RR               24.54             E0256       NU              870.84
       K0607      UE              183.94             E0256       RR              102.33
       K0608      NU              153.06             E0260       NU            1,142.49
       K0608      RR               15.33             E0260       RR              182.20
       K0608      UE              114.80             E0261       NU              931.67


900-1101-0409                              DME - 5                                   www.bcbsfl.com
                           Durable Medical Equipment
                Hospital Beds                                  Hospital Beds
       Code       Modifier    Allowance                Code      Modifier    Allowance
       E0261        RR              151.00             E0372       RR              640.42
       E0265        NU            1,875.70             E0373       NU            6,243.45
       E0265        RR              220.40             E0373       RR              733.61
       E0266        NU            1,666.49             E0870       NU              128.24
       E0266        RR              195.81             E0870       RR               17.39
       E0271        NU              244.83             E0880       NU              162.85
       E0271        RR               25.42             E0880       RR               21.76
       E0272        NU              247.72             E0890       NU              132.77
       E0272        RR               24.77             E0890       RR               34.24
       E0275        NU               16.88             E0910       NU              193.20
       E0275        RR                1.77             E0910       RR               25.94
       E0276        NU               15.35             E0911       NU              337.34
       E0276        RR                1.73             E0911       RR               55.03
       E0277        NU            6,714.47             E0920       NU              509.39
       E0277        RR              901.66             E0920       RR               59.85
       E0280        NU               48.00             E0946       NU              565.69
       E0280        RR                4.83             E0946       RR               66.47
       E0290        NU              825.13             E0947       NU              668.69
       E0290        RR               96.96             E0947       RR               69.35
       E0291        NU              599.47             E0948       NU              646.78
       E0291        RR               70.44             E0948       RR               64.65
       E0292        NU              872.71
       E0292        RR              102.55
       E0293        NU              743.10
       E0293        RR               87.31
       E0294        NU            1,225.99
       E0294        RR              144.06
       E0295        NU            1,195.08
       E0295        RR              140.43
       E0296        NU            1,540.85
       E0296        RR              181.06
       E0297        NU            1,320.05
       E0297        RR              155.11
       E0300        NU            3,682.25
       E0300        RR              368.23
       E0301        NU            3,442.91
       E0301        RR              340.21
       E0302        NU            5,726.45
       E0302        RR              789.84
       E0303        NU            2,365.58
       E0303        RR              326.29
       E0304        NU            6,168.45
       E0304        RR              850.83
       E0305        NU              166.92
       E0305        RR               19.61
       E0310        NU              238.56
       E0310        RR               25.10
       E0371        NU            4,491.73
       E0371        RR              527.78
       E0372        NU            5,450.34


900-1101-0409                                DME - 6                                   www.bcbsfl.com
                            Durable Medical Equipment
                Medical Supplies                               Medical Supplies
       Code        Modifier    Allowance               Code       Modifier    Allowance
       A4207          NU              0.95             A4355         NU               9.40
       A4208          NU              0.46             A4356         NU              59.82
       A4209          NU              0.46             A4357         NU              12.72
       A4212          NU              8.96             A4358         NU               8.69
       A4213          NU              0.92             A4359         NU              38.03
       A4215          NU              1.05             A4450         AU               0.12
       A4218          NU              0.12             A4450         AV               0.12
       A4220          NU             55.30             A4450        AW                0.12
       A4221          NU             44.65             A4450         NU               0.12
       A4222          NU             58.91             A4452         NU               0.47
       A4244          NU              0.92             A4452         AU               0.47
       A4246          NU              3.26             A4452         AV               0.47
       A4247          NU              5.11             A4452        AW                0.47
       A4262          NU              0.46             A4461         NU               4.40
       A4263          NU             43.62             A4462         NU               4.08
       A4265          NU              4.44             A4463         NU              17.83
       A4267          NU              0.53             A4465         NU              10.21
       A4269          NU              1.05             A4470         NU               6.96
       A4284          NU             19.50             A4480         NU               4.69
       A4290          NU            135.06             A4510         NU              13.46
       A4300          NU             38.93             A4534         NU               0.54
       A4305          NU             14.38             A4550         NU              32.02
       A4306          NU             19.50             A4559         NU               0.14
       A4310          NU              8.60             A4561         NU              23.17
       A4311          NU             15.87             A4562         NU              59.04
       A4312          NU             22.59             A4565         NU               7.89
       A4313          NU             19.82             A4630         NU               8.20
       A4314          NU             26.77             A4633         NU              53.05
       A4315          NU             28.41             A4635         NU               5.77
       A4316          NU             31.64             A4635         RR               0.79
       A4320          NU              6.98             A4635         UE               4.33
       A4322          NU              3.70             A4636         NU               4.49
       A4326          NU             13.73             A4636         RR               0.47
       A4327          NU             53.36             A4636         UE               3.37
       A4328          NU             12.49             A4637         NU               2.37
       A4330          NU              9.12             A4637         RR               0.35
       A4332          NU              0.15             A4637         UE               1.78
       A4333          NU              2.80             A4638         NU               0.00
       A4334          NU              6.46             A4638         RR               0.00
       A4335          NU              0.00             A4639         NU             380.49
       A4338          NU             16.08             A4640         NU              70.56
       A4340          NU             41.62             A4640         RR               7.19
       A4344          NU             21.00             A4640         UE              52.92
       A4346          NU             24.56             A4642         NU           1,001.62
       A4348          NU             34.98             A4660         NU              14.38
       A4349          NU              2.65             A4663         NU              27.85
       A4351          NU              2.37             A4670         NU              71.00
       A4352          NU              7.16             A4680         NU              60.57
       A4353          NU              9.16             A4690         NU             714.63
       A4354          NU             13.15             A4714         NU              51.98


900-1101-0409                                DME - 7                                    www.bcbsfl.com
                            Durable Medical Equipment
                Medical Supplies                                Medical Supplies
       Code       Modifier     Allowance                Code       Modifier    Allowance
       A4730         NU               59.12             A6222         NU              2.79
       A4740         NU               60.32             A6223         NU              3.17
       A4750         NU               11.73             A6224         NU              4.73
       A4755         NU                7.58             A6228         NU              1.86
       A4760         NU               41.47             A6229         NU              4.58
       A4765         NU                5.24             A6230         NU              3.26
       A4770         NU               24.04             A6231         NU              6.11
       A4771         NU                1.26             A6232         NU              8.67
       A4772         NU               28.77             A6233         NU             24.16
       A4773         NU               15.88             A6234         NU              8.57
       A4774         NU                8.79             A6235         NU             22.05
       A4802         NU                5.11             A6236         NU             34.33
       A4860         NU                4.76             A6237         NU             10.36
       A4870         NU            1,812.98             A6238         NU             28.55
       A4918         NU                1.26             A6239         NU             22.62
       A4927         NU                4.64             A6240         NU             15.30
       A4930         NU                0.92             A6241         NU              3.27
       A6010         NU               39.99             A6242         NU              7.96
       A6011         NU                2.99             A6243         NU             15.68
       A6021         NU               27.56             A6244         NU             49.50
       A6022         NU               27.56             A6245         NU              9.20
       A6023         NU              242.52             A6246         NU             12.52
       A6024         NU                8.11             A6247         NU             29.84
       A6025         NU               26.45             A6248         NU             21.29
       A6154         NU               18.26             A6250         NU             13.97
       A6196         NU                9.63             A6251         NU              2.61
       A6197         NU               21.56             A6252         NU              4.26
       A6198         NU              101.50             A6253         NU              8.31
       A6199         NU                6.64             A6254         NU              1.42
       A6200         NU               12.46             A6255         NU              3.89
       A6201         NU               26.51             A6256         NU              6.00
       A6202         NU               44.45             A6257         NU              2.00
       A6203         NU                4.39             A6258         NU              5.64
       A6204         NU                7.88             A6259         NU             13.83
       A6205         NU                9.03             A6260         NU              1.39
       A6206         NU                3.91             A6261         NU              4.64
       A6207         NU                9.25             A6262         NU              0.84
       A6208         NU               16.68             A6266         NU              2.51
       A6209         NU                9.81             A6402         NU              0.15
       A6210         NU               26.11             A6403         NU              0.57
       A6211         NU               36.98             A6404         NU              0.46
       A6212         NU               12.72             A6407         NU              2.47
       A6213         NU               19.54             A6410         NU              0.50
       A6214         NU               13.08             A6411         NU              0.52
       A6215         NU                3.30             A6447         NU              0.88
       A6216         NU                0.07             A6448         NU              1.52
       A6217         NU                0.59             A6449         NU              2.29
       A6218         NU                0.46             A6450         NU              0.00
       A6219         NU                1.24             A6451         NU              0.00
       A6220         NU                3.28             A6457         NU              1.48


900-1101-0409                                 DME - 8                                   www.bcbsfl.com
                            Durable Medical Equipment
                Medical Supplies                       Oxygen Equipment and Supplies
       Code        Modifier    Allowance               Code      Modifier   Allowance
       A6452          NU              7.74             A4481       NU               0.48
       A6453          NU              0.80             A4490       NU               7.42
       A6454          NU              1.01             A4495       NU               7.42
       A6455          NU              1.84             A4500       NU               5.58
       A6456          NU              1.70             A4556       NU              14.20
       A6501          NU              0.00             A4557       NU              27.67
       A6502          NU              0.00             A4558       NU               6.64
       A6503          NU              0.00             A4604       NU              90.03
       A6504          NU              0.00             A4605       NU              21.50
       A6505          NU              0.00             A4606       NU              23.64
       A6507          NU              0.00             A4608       NU              76.11
       A6509          NU              0.00             A4611       NU             250.32
       A6510          NU              0.00             A4611       RR              25.03
       A6511          NU              0.00             A4611       UE             187.74
       A6512          NU              0.00             A4612       NU             105.89
       A6513          NU              0.00             A4612       RR              10.78
       A6531          NU             56.19             A4612       UE              79.42
       A6532          NU             79.17             A4613       NU             173.18
       A6533          NU              0.00             A4613       RR              17.32
       A6534          NU              0.00             A4613       UE             129.89
       A6535          NU              0.00             A4614       NU              29.38
       A6536          NU              0.00             A4615       NU               1.86
       A6538          NU              0.00             A4616       NU               0.46
       A6539          NU              0.00             A4617       NU               7.42
       A6541          NU              0.00             A4618       NU               9.91
       A6542          NU              0.00             A4618       RR               1.16
       A6543          NU             28.84             A4618       UE               7.43
       A6545          NU              0.00             A4619       NU               1.59
       A6550          NU             35.95             A4620       NU               0.90
       A7000          NU             11.94             A4623       NU               8.58
       A7001          NU             34.76             A4624       NU               3.45
       A7002          NU              4.28             A4625       NU               8.67
       A9282          NU              0.00             A4626       NU               3.37
       E0676          NU              0.00             A4627       NU              18.56
       E0676          RR              0.00             A4628       NU               4.82
       E0936          RR              0.00             A4629       NU               6.07
       E1038          NU            161.13             A7003       NU               3.41
       E1220          NU              0.00             A7004       NU               2.00
       K0730          NU              0.00             A7005       NU              34.36
                                                       A7006       NU              12.43
             Negative Pressure                         A7007       NU               5.24
              Wound Therapy                            A7008       NU              11.96
       Code      Modifier    Allowance                 A7009       NU              49.93
       E2402        RR           2,226.59              A7010       NU              26.29
                                                       A7011       NU              22.27
                                                       A7012       NU               4.55
                                                       A7013       NU               0.92
                                                       A7014       NU               5.67
                                                       A7015       NU               2.47
                                                       A7016       NU               8.54


900-1101-0409                                DME - 9                                  www.bcbsfl.com
                          Durable Medical Equipment
       Oxygen Equipment and Supplies                  Oxygen Equipment and Supplies
       Code      Modifier   Allowance                 Code      Modifier   Allowance
       A7017       NU             175.73              E0445       NU             672.17
       A7017       RR              17.75              E0445       RR             113.85
       A7017       UE             131.80              E0450       NU          10,537.90
       A7018       NU               0.41              E0450       RR           1,238.21
       A7025       NU             562.20              E0455       NU             439.88
       A7026       NU              37.16              E0455       RR              44.08
       A7030       NU             247.31              E0457       NU             797.14
       A7031       NU              91.47              E0457       RR              79.71
       A7032       NU              53.13              E0457       UE             597.86
       A7033       NU              37.25              E0459       NU             518.66
       A7034       NU             154.23              E0459       RR              60.94
       A7035       NU              45.48              E0460       NU           8,098.61
       A7036       NU              20.29              E0460       RR             951.59
       A7037       NU              50.25              E0461       RR           1,299.86
       A7038       NU               6.72              E0462       NU           3,217.06
       A7039       NU              17.08              E0462       RR             378.01
       A7041       NU             102.99              E0463       RR           1,824.36
       A7042       NU             219.96              E0464       RR           1,824.36
       A7043       NU              30.88              E0470       NU           3,021.70
       A7044       NU             158.51              E0470       RR             302.16
       A7045       NU              25.53              E0471       NU           7,005.60
       A7045       UE              19.15              E0471       RR             708.06
       A7046       NU              25.57              E0472       NU           7,005.60
       A7501       NU             133.86              E0472       RR             708.06
       A7502       NU              63.62              E0480       NU             360.87
       A7503       NU              14.43              E0480       RR              48.45
       A7504       NU               0.88              E0482       RR             510.61
       A7505       NU               5.96              E0483       RR           1,379.09
       A7506       NU               0.43              E0484       NU              47.89
       A7507       NU               3.17              E0484       RR               4.79
       A7508       NU               3.77              E0484       UE              35.92
       A7509       NU               1.79              E0500       NU           1,211.86
       A7520       NU              62.25              E0500       RR             142.39
       A7521       NU              61.69              E0550       NU             553.44
       A7522       NU              59.20              E0550       RR              65.03
       A7524       NU             102.34              E0555       NU               7.89
       A7525       NU               2.72              E0555       RR               4.69
       A7526       NU               4.42              E0560       NU             197.15
       A7527       NU               4.75              E0560       RR              25.75
       E0424       RR             259.95              E0560       UE             147.86
       E0425       NU           3,660.78              E0561       NU             138.80
       E0430       NU           1,583.78              E0561       RR              13.87
       E0431       RR              41.61              E0561       UE             104.10
       E0434       RR              41.61              E0562       NU             390.75
       E0439       RR             221.24              E0562       RR              39.05
       E0440       NU           2,313.90              E0562       UE             293.06
       E0441       NU             179.70              E0565       NU             500.94
       E0442       NU             179.70              E0565       RR              67.28
       E0443       NU              23.61              E0570       NU             208.85
       E0444       NU              23.61              E0570       RR              20.88


900-1101-0409                              DME - 10                                  www.bcbsfl.com
                          Durable Medical Equipment
       Oxygen Equipment and Supplies                     Orthotics and Prosthetics
       Code      Modifier   Allowance                 Code       Modifier    Allowance
       E0571       NU             304.59              A4280         NU                6.53
       E0571       RR              35.78              A4600         NU                0.00
       E0572       NU             387.17              A4600         RR                0.00
       E0572       RR              45.50              A5508         NU                0.00
       E0574       NU             344.59              A5510         NU               43.57
       E0574       RR              48.07              A5512         NU               31.75
       E0575       NU             977.45              A5513         NU               47.38
       E0575       RR             131.27              L0112         NU            1,250.69
       E0580       NU             173.88              L0113         NU                0.00
       E0580       RR              17.39              L0120         NU               25.01
       E0580       UE             130.41              L0130         NU              180.78
       E0585       NU             373.59              L0140         NU               62.38
       E0585       RR              43.90              L0150         NU              104.02
       E0600       NU             442.29              L0160         NU              148.10
       E0600       RR              59.40              L0170         NU              626.75
       E0601       NU           1,123.87              L0172         NU              127.08
       E0601       RR             123.17              L0174         NU              228.29
       E0602       NU              38.34              L0180         NU              310.49
       E0602       RR               3.84              L0190         NU              467.38
       E0602       UE              28.75              L0200         NU              429.15
       E0605       NU              33.67              L0210         NU               44.55
       E0605       RR               3.96              L0220         NU              101.78
       E0605       UE              25.25              L0450         NU              168.03
       E1354       NU               0.00              L0452         NU              365.01
       E1356       NU               0.00              L0454         NU              309.92
       E1357       NU               0.00              L0456         NU              888.75
       E1358       NU               0.00              L0458         NU              796.95
       E1390       NU           2,614.27              L0460         NU              897.03
       E1390       RR             259.95              L0462         NU            1,115.74
       E1391       RR             259.95              L0464         NU            1,328.28
       E1392       RR              73.76              L0466         NU              341.55
       E1405       NU           2,585.90              L0468         NU              428.21
       E1405       RR             303.85              L0470         NU              609.67
       E1406       NU           2,390.05              L0472         NU              382.67
       E1406       RR             280.83              L0474         NU              581.82
                                                      L0480         NU            1,183.35
                                                      L0482         NU            1,356.55
                                                      L0484         NU            1,581.71
                                                      L0486         NU            1,566.88
                                                      L0488         NU              897.03
                                                      L0490         NU              252.77
                                                      L0491         NU              686.27
                                                      L0492         NU              444.77
                                                      L0621         NU               79.68
                                                      L0622         NU              216.05
                                                      L0624         NU              414.00
                                                      L0625         NU               49.24
                                                      L0626         NU               69.66
                                                      L0627         NU              367.33
                                                      L0628         NU               74.95


900-1101-0409                              DME - 11                                     www.bcbsfl.com
                            Durable Medical Equipment
          Orthotics and Prosthetics                         Orthotics and Prosthetics
       Code       Modifier    Allowance                  Code       Modifier    Allowance
       L0629         NU              310.50              L1260         NU               82.26
       L0630         NU              144.71              L1270         NU               82.15
       L0631         NU              917.34              L1280         NU               73.24
       L0632         NU              448.50              L1290         NU               83.05
       L0633         NU              256.24              L1300         NU            1,388.20
       L0634         NU              621.00              L1310         NU            1,428.47
       L0635         NU              950.23              L1500         NU            1,578.54
       L0636         NU            1,402.11              L1510         NU              998.65
       L0637         NU            1,216.53              L1520         NU            2,371.97
       L0638         NU            1,178.58              L1600         NU              107.09
       L0639         NU            1,216.53              L1610         NU               36.49
       L0640         NU              935.06              L1620         NU              120.14
       L0700         NU            1,923.93              L1630         NU              143.37
       L0710         NU            2,100.11              L1640         NU              383.46
       L0810         NU            2,231.05              L1650         NU              203.34
       L0820         NU            1,804.82              L1652         NU              318.53
       L0830         NU            2,605.96              L1660         NU              142.22
       L0859         NU            1,012.40              L1680         NU            1,169.27
       L0861         NU              192.62              L1685         NU            1,233.78
       L0970         NU               94.97              L1686         NU              827.70
       L0972         NU               97.08              L1690         NU            1,728.01
       L0974         NU              198.39              L1700         NU            1,437.59
       L0976         NU              177.16              L1710         NU            1,689.80
       L0978         NU              159.97              L1720         NU            1,248.25
       L0980         NU               14.50              L1730         NU              941.79
       L0982         NU               15.81              L1755         NU            1,370.77
       L0984         NU               50.45              L1800         NU               73.72
       L1000         NU            1,687.22              L1810         NU              108.19
       L1001         NU                0.00              L1815         NU               99.15
       L1005         NU            2,860.09              L1820         NU              107.75
       L1010         NU               67.94              L1825         NU               48.04
       L1020         NU               92.82              L1830         NU               90.14
       L1025         NU              105.51              L1831         NU              263.00
       L1030         NU               70.49              L1832         NU              673.66
       L1040         NU               84.86              L1834         NU              792.53
       L1050         NU               73.47              L1836         NU              119.23
       L1060         NU               82.87              L1840         NU              833.11
       L1070         NU               84.70              L1843         NU              801.79
       L1080         NU               58.71              L1844         NU            1,389.32
       L1085         NU              163.09              L1845         NU              837.00
       L1090         NU               76.18              L1846         NU            1,049.05
       L1100         NU              134.48              L1847         NU              513.98
       L1110         NU              227.77              L1850         NU              239.21
       L1120         NU               36.29              L1860         NU              927.79
       L1200         NU            1,444.25              L1900         NU              251.35
       L1210         NU              217.46              L1901         NU               15.81
       L1220         NU              184.12              L1902         NU               68.25
       L1230         NU              472.42              L1904         NU              390.79
       L1240         NU               81.30              L1906         02              114.20
       L1250         NU               80.05              L1906         NU              114.20


900-1101-0409                                 DME - 12                                     www.bcbsfl.com
                            Durable Medical Equipment
          Orthotics and Prosthetics                         Orthotics and Prosthetics
       Code       Modifier    Allowance                  Code       Modifier    Allowance
       L1907         NU              502.83              L2188         NU              331.85
       L1910         NU              222.24              L2190         NU               86.19
       L1920         02              290.53              L2200         NU               39.51
       L1920         NU              290.53              L2210         NU               64.11
       L1930         NU              196.59              L2220         NU               73.61
       L1932         NU              797.39              L2230         NU               63.77
       L1940         02              444.28              L2240         NU               69.50
       L1940         NU              444.28              L2250         NU              295.29
       L1945         NU              815.88              L2260         NU              166.59
       L1950         NU              619.00              L2265         NU               97.87
       L1951         NU              750.47              L2270         NU               44.63
       L1960         02              460.63              L2275         NU              108.59
       L1960         NU              460.63              L2280         NU              403.43
       L1970         02              681.31              L2300         NU              227.73
       L1970         NU              681.31              L2310         NU              102.23
       L1971         NU              418.86              L2320         NU              170.98
       L1980         NU              305.01              L2330         NU              326.31
       L1990         NU              391.88              L2335         NU              191.96
       L2000         NU              842.92              L2340         NU              453.00
       L2005         NU            3,661.72              L2350         NU              740.49
       L2010         NU              768.40              L2360         NU               43.00
       L2020         NU              970.37              L2370         NU              213.33
       L2030         NU              841.88              L2375         NU               93.90
       L2034         NU            1,834.82              L2380         NU              102.31
       L2035         NU              154.81              L2385         NU              111.31
       L2036         NU            1,541.86              L2387         NU              151.07
       L2037         NU            1,420.92              L2390         NU               90.97
       L2038         NU            1,188.17              L2395         NU              138.90
       L2040         NU              151.77              L2397         NU               97.40
       L2050         NU              404.19              L2405         NU               77.91
       L2060         NU              518.74              L2415         NU              108.55
       L2070         NU              149.01              L2425         NU              128.08
       L2080         NU              317.77              L2430         NU              128.08
       L2090         NU              391.71              L2492         NU               84.75
       L2106         NU              565.04              L2500         NU              262.17
       L2108         NU              887.93              L2510         NU              701.95
       L2112         02              421.60              L2520         NU              382.84
       L2112         NU              421.60              L2525         NU            1,313.46
       L2114         02              482.37              L2526         NU              707.97
       L2114         NU              482.37              L2530         NU              195.27
       L2116         NU              635.55              L2540         NU              351.35
       L2126         NU            1,130.76              L2550         NU              238.67
       L2128         NU            1,425.02              L2570         NU              527.78
       L2132         NU              670.38              L2580         NU              500.31
       L2134         NU              803.77              L2600         NU              170.68
       L2136         NU              982.79              L2610         NU              201.83
       L2180         NU               97.32              L2620         NU              222.21
       L2182         NU               76.16              L2622         NU              254.84
       L2184         NU              137.25              L2624         NU              346.46
       L2186         NU              152.10              L2627         NU            1,427.38


900-1101-0409                                 DME - 13                                     www.bcbsfl.com
                            Durable Medical Equipment
          Orthotics and Prosthetics                         Orthotics and Prosthetics
       Code       Modifier    Allowance                  Code       Modifier    Allowance
       L2628         NU            1,676.73              L3213         NU              62.42
       L2630         NU              205.79              L3214         NU              66.54
       L2640         NU              279.28              L3215         NU              84.75
       L2650         NU               99.73              L3216         NU             102.52
       L2660         NU              154.89              L3217         NU             111.20
       L2670         NU              141.77              L3219         NU              95.08
       L2680         NU              130.05              L3221         NU             114.08
       L2750         NU               69.47              L3222         NU             126.08
       L2755         NU              116.78              L3224         NU              48.87
       L2760         NU               50.48              L3225         NU              56.22
       L2768         NU              116.44              L3230         NU             148.41
       L2770         NU               51.31              L3250         NU             288.53
       L2780         NU               59.73              L3251         NU              39.69
       L2785         NU               35.12              L3252         NU             157.90
       L2795         NU               70.61              L3253         NU              39.69
       L2800         NU               88.64              L3257         NU              28.52
       L2810         NU               64.90              L3260         NU              16.12
       L2820         NU               72.17              L3265         NU              17.36
       L2830         NU               81.16              L3300         NU              46.59
       L2840         NU               45.29              L3310         NU              72.73
       L2850         NU               51.46              L3320         NU             106.65
       L2860         NU              379.47              L3330         NU             505.71
       L3000         NU              280.72              L3332         NU              65.91
       L3001         NU              118.18              L3334         NU              34.09
       L3002         NU              144.32              L3340         NU              76.16
       L3003         NU              155.69              L3350         NU              20.44
       L3010         NU              155.69              L3360         NU              31.82
       L3020         NU              177.29              L3370         NU              44.33
       L3030         NU               68.19              L3380         NU              44.33
       L3040         NU               42.05              L3390         NU              44.33
       L3050         NU               42.05              L3400         NU              36.38
       L3060         NU               65.91              L3410         NU              82.98
       L3070         NU               28.41              L3420         NU              48.85
       L3080         NU               28.41              L3430         NU             143.20
       L3090         NU               36.38              L3440         NU              68.19
       L3100         NU               38.63              L3450         NU              94.31
       L3140         NU               79.56              L3455         NU              36.38
       L3150         NU               72.73              L3460         NU              30.66
       L3160         NU               11.99              L3465         NU              52.26
       L3170         NU               45.47              L3470         NU              55.67
       L3201         NU               46.30              L3480         NU              55.67
       L3202         NU               45.47              L3485         NU              16.12
       L3203         NU               44.23              L3500         NU              26.15
       L3204         NU               44.23              L3510         NU              26.15
       L3206         NU               46.30              L3520         NU              28.41
       L3207         NU               47.11              L3530         NU              28.41
       L3208         NU               24.38              L3540         NU              45.47
       L3209         NU               34.72              L3550         NU               7.98
       L3211         NU               37.20              L3560         NU              20.44
       L3212         NU               51.67              L3570         NU              76.16


900-1101-0409                                 DME - 14                                    www.bcbsfl.com
                            Durable Medical Equipment
          Orthotics and Prosthetics                         Orthotics and Prosthetics
       Code       Modifier    Allowance                  Code       Modifier    Allowance
       L3580         NU               57.95              L3913         NU              220.26
       L3590         NU               47.72              L3915         NU              455.65
       L3595         NU               37.49              L3917         NU               85.91
       L3600         NU               68.19              L3919         NU              220.26
       L3610         NU               89.78              L3921         NU              261.22
       L3620         NU               68.19              L3923         NU               31.66
       L3630         NU               89.78              L3925         NU               43.36
       L3640         NU               38.63              L3927         NU                0.00
       L3650         NU               48.67              L3929         NU               69.08
       L3651         NU               53.53              L3931         NU              167.12
       L3652         NU              161.38              L3933         NU              173.52
       L3660         NU               83.59              L3935         NU              179.68
       L3670         NU              116.50              L3960         NU              670.35
       L3671         NU              732.78              L3961         NU            1,366.37
       L3672         NU              911.28              L3962         NU              697.98
       L3673         NU              993.21              L3964         NU              685.71
       L3675         NU              142.72              L3964         RR               68.56
       L3677         NU              149.24              L3965         NU            1,094.19
       L3700         02               56.77              L3965         RR              109.43
       L3700         NU               56.77              L3966         NU              824.29
       L3701         NU               16.56              L3966         RR               82.44
       L3702         NU              234.82              L3967         NU            1,613.21
       L3710         NU              117.91              L3968         NU            1,043.13
       L3720         NU              588.25              L3968         RR              104.30
       L3730         02              774.37              L3969         NU              729.45
       L3730         NU              774.37              L3969         RR               72.95
       L3740         NU              870.26              L3970         NU              291.80
       L3760         NU              406.70              L3970         RR               29.17
       L3762         NU               87.45              L3971         NU            1,531.28
       L3762         NU              945.77              L3972         NU              240.87
       L3764         NU            1,104.25              L3972         RR               24.09
       L3765         NU            1,042.78              L3973         NU            1,613.21
       L3766         NU            1,104.25              L3974         NU              154.48
       L3806         NU              473.93              L3974         RR               15.44
       L3807         02              203.34              L3975         NU            1,366.37
       L3807         NU              203.34              L3976         NU            1,366.37
       L3808         NU              291.81              L3977         NU            1,531.28
       L3890         NU              392.83              L3978         NU            1,613.21
       L3900         NU            1,270.44              L3980         NU              251.41
       L3901         NU            1,424.51              L3982         02              310.61
       L3904         NU            2,899.89              L3982         NU              310.61
       L3905         NU              806.50              L3984         NU              331.56
       L3906         02              343.08              L3995         NU               27.83
       L3906         NU              343.08              L4000         NU            1,084.13
       L3908         02               48.73              L4002         NU               33.95
       L3908         NU               48.73              L4010         NU              610.08
       L3909         NU               11.51              L4020         NU              762.05
       L3911         NU               20.18              L4030         NU              419.58
       L3912         02               78.18              L4040         NU              339.23
       L3912         NU               78.18              L4045         NU              272.61


900-1101-0409                                 DME - 15                                     www.bcbsfl.com
                            Durable Medical Equipment
          Orthotics and Prosthetics                         Orthotics and Prosthetics
       Code       Modifier    Allowance                  Code       Modifier    Allowance
       L4050         NU              343.10              L5510         NU            1,288.99
       L4055         NU              222.15              L5520         NU            1,273.22
       L4060         NU              264.10              L5530         NU            1,529.25
       L4070         NU              251.99              L5535         NU            1,501.41
       L4080         NU               88.83              L5540         NU            1,602.48
       L4090         NU               78.63              L5560         NU            1,720.79
       L4100         NU               88.68              L5570         NU            1,789.02
       L4110         NU               70.48              L5580         NU            2,088.55
       L4130         NU              485.04              L5585         NU            2,570.31
       L4205         NU               19.09              L5590         NU            2,128.37
       L4210         NU               20.70              L5595         NU            3,760.09
       L4350         02               87.40              L5600         NU            4,041.90
       L4350         NU               87.40              L5610         NU            1,833.07
       L4360         NU              244.48              L5611         NU            1,426.49
       L4370         NU              156.89              L5613         NU            2,230.26
       L4380         NU               96.19              L5614         NU            1,510.85
       L4386         NU              141.68              L5616         NU            1,205.22
       L4392         NU               21.05              L5617         NU              500.95
       L4394         NU               15.36              L5618         NU              265.02
       L4396         NU              149.98              L5620         NU              246.15
       L4398         NU               69.01              L5622         NU              320.96
       L5000         NU              468.57              L5624         NU              321.89
       L5010         NU            1,131.66              L5626         NU              422.14
       L5020         NU            1,921.86              L5628         NU              451.37
       L5050         NU            2,125.92              L5629         NU              281.38
       L5060         NU            2,445.40              L5630         NU              397.36
       L5100         NU            2,130.60              L5631         NU              389.02
       L5105         NU            3,075.74              L5632         NU              217.12
       L5150         NU            3,109.15              L5634         NU              269.32
       L5160         NU            3,381.76              L5636         NU              225.59
       L5200         NU            3,238.52              L5637         NU              255.77
       L5210         NU            2,148.43              L5638         NU              445.55
       L5220         NU            2,442.08              L5639         NU              992.66
       L5230         NU            3,368.11              L5640         NU              566.15
       L5250         NU            4,593.80              L5642         NU              548.55
       L5270         NU            4,573.42              L5643         NU            1,378.04
       L5280         NU            4,538.39              L5644         NU              522.94
       L5301         NU            2,435.40              L5645         NU              706.42
       L5311         NU            3,486.13              L5646         NU              485.11
       L5321         NU            3,530.18              L5647         NU              704.27
       L5331         NU            4,498.17              L5648         NU              582.91
       L5341         NU            4,682.62              L5649         NU            2,112.20
       L5400         NU            1,205.73              L5650         NU              432.23
       L5410         NU              369.92              L5651         NU            1,063.26
       L5420         NU            1,477.59              L5652         NU              386.00
       L5430         NU              445.53              L5653         NU              515.28
       L5450         NU              362.46              L5654         NU              293.62
       L5460         NU              482.89              L5655         NU              248.83
       L5500         NU            1,137.11              L5656         NU              333.82
       L5505         NU            1,572.66              L5658         NU              321.91


900-1101-0409                                 DME - 16                                     www.bcbsfl.com
                            Durable Medical Equipment
          Orthotics and Prosthetics                         Orthotics and Prosthetics
       Code       Modifier    Allowance                  Code       Modifier    Allowance
       L5661         NU              538.78              L5795         NU            1,267.49
       L5665         NU              453.33              L5810         NU              431.06
       L5666         NU               61.98              L5811         NU              645.72
       L5668         NU               99.97              L5812         NU              500.50
       L5670         NU              240.24              L5814         NU            3,325.19
       L5671         NU              509.10              L5816         NU              757.48
       L5672         NU              264.01              L5818         NU              850.25
       L5673         NU              629.54              L5822         NU            1,507.71
       L5676         NU              320.84              L5824         NU            1,357.78
       L5677         NU              436.55              L5826         NU            2,796.06
       L5678         NU               35.15              L5828         NU            2,500.23
       L5679         NU              524.61              L5830         NU            1,680.03
       L5680         NU              293.44              L5840         NU            3,106.37
       L5681         NU            1,177.73              L5845         NU            1,604.79
       L5682         NU              553.71              L5848         NU              962.76
       L5683         NU            1,177.73              L5850         NU              113.26
       L5684         NU               42.61              L5855         NU              304.35
       L5685         NU              114.68              L5856         NU          21,493.44
       L5686         NU               45.24              L5857         NU            7,626.65
       L5688         NU               54.08              L5910         NU              320.66
       L5690         NU               86.64              L5920         NU              469.77
       L5692         NU              117.65              L5925         NU              396.65
       L5694         NU              160.62              L5930         NU            3,013.62
       L5695         NU              148.28              L5940         NU              444.11
       L5696         NU              163.81              L5950         NU              694.40
       L5697         NU               71.07              L5960         NU              853.53
       L5698         NU              116.22              L5962         NU              561.72
       L5699         NU              209.37              L5964         NU              829.17
       L5700         NU            2,536.76              L5966         NU            1,056.56
       L5701         NU            3,046.46              L5968         NU            3,253.61
       L5702         NU            3,854.23              L5970         NU              179.81
       L5703         NU            1,994.60              L5971         NU              179.81
       L5704         NU              474.57              L5972         NU              335.86
       L5705         NU              847.95              L5974         NU              206.31
       L5706         NU              831.23              L5975         NU              415.08
       L5707         NU            1,095.86              L5976         NU              495.83
       L5710         NU              331.12              L5978         NU              258.38
       L5711         NU              462.77              L5979         NU            2,020.21
       L5712         NU              387.77              L5980         NU            3,282.72
       L5714         NU              398.30              L5981         NU            2,651.97
       L5716         NU              645.30              L5982         NU              511.84
       L5718         NU              806.55              L5984         NU              504.38
       L5722         NU              852.09              L5985         NU              252.82
       L5724         NU            1,336.39              L5986         NU              561.04
       L5726         NU            1,540.16              L5987         NU            6,440.87
       L5728         NU            2,106.74              L5988         NU            1,788.62
       L5780         NU            1,013.67              L5990         NU            1,624.34
       L5781         NU            3,582.42              L5993         NU                0.00
       L5785         NU              569.80              L5994         NU                0.00
       L5790         NU              636.59              L6000         NU            1,176.39


900-1101-0409                                 DME - 17                                     www.bcbsfl.com
                            Durable Medical Equipment
          Orthotics and Prosthetics                         Orthotics and Prosthetics
       Code       Modifier    Allowance                  Code       Modifier    Allowance
       L6010         NU            1,309.12              L6638         NU            2,239.01
       L6020         NU            1,220.55              L6639         NU            1,751.85
       L6025         NU            7,164.85              L6640         NU              295.49
       L6050         NU            1,681.88              L6641         NU              142.03
       L6055         NU            2,344.10              L6642         NU              192.51
       L6100         NU            1,704.00              L6645         NU              355.36
       L6110         NU            1,807.39              L6646         NU            2,823.89
       L6120         NU            2,106.24              L6647         NU              464.88
       L6130         NU            2,291.99              L6648         NU            2,912.43
       L6200         NU            2,415.37              L6650         NU              368.96
       L6205         NU            3,224.15              L6655         NU               72.52
       L6250         NU            2,530.75              L6660         NU               81.27
       L6300         NU            3,298.56              L6665         NU               40.78
       L6310         NU            2,848.17              L6670         NU               45.07
       L6320         NU            1,555.89              L6672         NU              178.92
       L6350         NU            3,467.94              L6675         NU              106.33
       L6360         NU            3,118.87              L6676         NU              122.90
       L6370         NU            1,866.23              L6680         NU              205.43
       L6380         NU            1,081.44              L6682         NU              227.12
       L6382         NU            1,626.99              L6684         NU              308.61
       L6384         NU            2,250.75              L6686         NU              696.93
       L6386         NU              355.56              L6687         NU              510.68
       L6388         NU              389.23              L6688         NU              507.62
       L6400         NU            2,054.41              L6689         NU              608.18
       L6450         NU            2,744.65              L6690         NU              662.75
       L6500         NU            2,871.48              L6691         NU              306.76
       L6550         NU            3,451.56              L6692         NU              495.13
       L6570         NU            3,875.16              L6693         NU            2,541.86
       L6580         NU            1,479.46              L6694         NU              629.54
       L6582         NU            1,339.99              L6695         NU              524.61
       L6584         NU            2,101.44              L6696         NU            1,177.73
       L6586         NU            1,966.61              L6697         NU            1,177.73
       L6588         NU            2,584.09              L6698         NU              509.10
       L6590         NU            2,454.50              L6703         NU              409.25
       L6600         NU              166.07              L6704         NU              659.27
       L6605         NU              163.97              L6706         NU              392.79
       L6610         NU              157.47              L6707         NU            1,447.74
       L6611         NU              472.91              L6708         NU              946.45
       L6615         NU              169.68              L6709         NU            1,363.85
       L6616         NU               62.87              L6711         NU              638.75
       L6620         NU              271.49              L6712         NU            1,176.09
       L6623         NU              757.25              L6713         NU            1,484.32
       L6624         NU            4,325.82              L6714         NU            1,257.22
       L6625         NU              538.05              L6721         NU            2,234.60
       L6628         NU              424.13              L6722         NU            1,926.37
       L6629         NU              129.53              L6805         NU              301.24
       L6630         NU              190.81              L6810         NU              170.75
       L6632         NU               66.27              L6881         NU            3,660.35
       L6635         NU              155.94              L6882         NU            2,776.57
       L6637         NU              332.62              L6883         NU            1,404.98


900-1101-0409                                 DME - 18                                     www.bcbsfl.com
                            Durable Medical Equipment
          Orthotics and Prosthetics                         Orthotics and Prosthetics
       Code       Modifier    Allowance                  Code       Modifier    Allowance
       L6884         NU            2,085.28              L7520         NU               31.26
       L6885         NU            3,118.87              L7611         NU                0.00
       L6890         NU              150.59              L7612         NU                0.00
       L6895         NU              553.97              L7613         NU                0.00
       L6900         NU            1,580.91              L7614         NU                0.00
       L6905         NU            1,571.93              L7621         NU                0.00
       L6910         NU            1,344.18              L7622         NU                0.00
       L6915         NU              677.70              L7900         NU              484.57
       L6920         NU            5,908.75              L8000         NU               38.94
       L6925         NU            7,954.18              L8001         NU              112.30
       L6930         NU            5,945.39              L8002         NU              147.73
       L6935         NU            8,077.61              L8010         NU               36.38
       L6940         NU            7,768.03              L8015         NU               53.67
       L6945         NU            9,491.61              L8020         NU              201.85
       L6950         NU            8,829.45              L8030         NU              291.98
       L6955         NU          10,574.47               L8035         NU            3,280.19
       L6960         NU          11,978.25               L8039         NU                0.00
       L6965         NU          12,775.23               L8040         NU            2,164.20
       L6970         NU          13,312.00               L8041         NU            2,608.52
       L6975         NU          14,559.06               L8042         NU            2,930.91
       L7007         NU            3,873.69              L8043         NU            3,282.63
       L7008         NU            6,096.78              L8044         NU            3,634.34
       L7009         NU            3,952.39              L8045         NU            2,275.92
       L7040         NU            2,496.02              L8046         NU            2,344.73
       L7045         NU            1,431.06              L8047         NU            1,201.68
       L7170         NU            6,589.10              L8300         NU               86.22
       L7180         NU          28,922.56               L8310         NU              132.59
       L7185         NU            6,506.84              L8320         NU               57.92
       L7186         NU            7,831.61              L8330         NU               57.41
       L7190         NU            6,834.39              L8400         NU               16.78
       L7191         NU            8,183.58              L8410         NU               19.09
       L7260         NU            1,742.44              L8415         NU               18.98
       L7261         NU            3,171.90              L8417         NU               67.32
       L7266         NU            1,168.78              L8420         NU               22.19
       L7272         NU            2,023.99              L8430         NU               24.40
       L7274         NU            5,085.22              L8435         NU               21.90
       L7360         NU              211.26              L8440         NU               46.42
       L7362         NU              221.82              L8460         NU               64.60
       L7364         NU              352.81              L8465         NU               57.59
       L7366         NU              475.24              L8470         NU                5.91
       L7367         NU              348.56              L8480         NU                8.14
       L7368         NU              451.87              L8485         NU                9.85
       L7400         NU              274.43              L8500         NU              584.32
       L7401         NU              307.20              L8501         NU              129.78
       L7402         NU              331.74              L8507         NU               37.51
       L7403         NU              329.74              L8509         NU               97.79
       L7404         NU              497.63              L8510         NU              226.25
       L7405         NU              650.82              L8600         NU              552.87
       L7500         NU              119.38              L8603         NU              388.29
       L7510         NU               27.60              L8606         NU              203.83


900-1101-0409                                 DME - 19                                     www.bcbsfl.com
                            Durable Medical Equipment
          Orthotics and Prosthetics                         Orthotics and Prosthetics
       Code       Modifier    Allowance                  Code       Modifier    Allowance
       L8610         NU              567.10              Q4038         NU              129.75
       L8612         NU              598.12              Q4039         NU               32.25
       L8613         NU              267.80              Q4040         NU               64.87
       L8614         NU          16,950.24               Q4041         NU               34.97
       L8619         NU            7,271.03              Q4042         NU               78.14
       L8630         NU              298.29              Q4043         NU               17.60
       L8641         NU              323.73              Q4044         NU               39.27
       L8642         NU              265.75              Q4045         NU               23.98
       L8658         NU              277.74              Q4046         NU               49.46
       L8670         NU              492.84              Q4047         NU               11.99
       L8690         NU            5,543.43              Q4048         NU               25.63
       L8691         NU            3,062.85              Q4049         NU               31.42
       L8695         NU               18.98              Q9954         NU               11.60
       Q4001         NU              136.00              Q9955         NU               20.38
       Q4002         NU              292.01              S1040         NU            3,530.59
       Q4003         NU               73.58              S8262         NU                0.00
       Q4004         NU              171.84              S8421         NU              132.67
       Q4005         NU               40.50              S8424         NU               12.20
       Q4006         NU               81.67              S8427         NU              130.76
       Q4007         NU               19.14              S8428         NU               79.98
       Q4008         NU               40.64              V2623         NU              794.74
       Q4009         NU               30.99              V2624         NU               53.90
       Q4010         NU               62.91              V2625         NU              349.11
       Q4011         NU               15.70              V2626         NU              221.49
       Q4012         NU               31.66              V2627         NU            1,268.08
       Q4013         NU               27.77              V2628         NU              289.94
       Q4014         NU               62.83
       Q4015         NU               14.01
       Q4016         NU               31.42
       Q4017         NU               25.63
       Q4018         NU               54.98
       Q4019         NU               12.82
       Q4020         NU               27.28
       Q4021         NU               25.63
       Q4022         NU               54.98
       Q4023         NU               12.82
       Q4024         NU               25.79
       Q4025         NU              114.08
       Q4026         NU              242.65
       Q4027         NU               57.05
       Q4028         NU              121.52
       Q4029         NU               56.22
       Q4030         NU              120.53
       Q4031         NU               28.11
       Q4032         NU               60.28
       Q4033         NU               46.13
       Q4034         NU              104.04
       Q4035         NU               23.02
       Q4036         NU               51.97
       Q4037         NU               64.49


900-1101-0409                                 DME - 20                                     www.bcbsfl.com
                           Durable Medical Equipment
                Ostomy Supplies                                Ostomy Supplies
       Code        Modifier   Allowance                Code       Modifier   Allowance
       A4331         NU              4.17              A4416        NU              3.60
       A4361         NU             23.83              A4417        NU              4.87
       A4362         NU              4.44              A4418        NU              2.37
       A4364         NU              3.44              A4419        NU              2.28
       A4365         NU             14.84              A4421        NU              0.00
       A4366         NU              1.71              A4422        NU              0.15
       A4367         NU              9.63              A4423        NU              2.44
       A4368         NU              0.35              A4424        NU              6.22
       A4369         NU              3.17              A4425        NU              4.69
       A4371         NU              4.79              A4426        NU              3.57
       A4372         NU              5.40              A4427        NU              3.64
       A4373         NU              8.24              A4428        NU              8.53
       A4375         NU             22.52              A4429        NU             10.82
       A4376         NU             62.38              A4430        NU             11.16
       A4377         NU              5.63              A4431        NU              8.24
       A4378         NU             39.76              A4432        NU              4.71
       A4379         NU             19.43              A4433        NU              4.37
       A4380         NU             49.31              A4434        NU              4.93
       A4381         NU              6.04              A4455        NU              1.60
       A4382         NU             31.82              A5051        NU              2.72
       A4383         NU             36.45              A5052        NU              1.97
       A4384         NU             12.43              A5053        NU              2.11
       A4385         NU              6.69              A5055        NU              1.89
       A4387         NU              4.71              A5061        NU              4.61
       A4388         NU              5.71              A5062        NU              2.72
       A4389         NU              8.16              A5063        NU              3.55
       A4390         NU             12.60              A5071        NU              7.88
       A4391         NU              9.12              A5072        NU              3.92
       A4392         NU             10.72              A5073        NU              3.59
       A4393         NU             11.85              A5081        NU              4.18
       A4394         NU              3.38              A5082        NU             13.25
       A4395         NU              0.07              A5093        NU              2.55
       A4396         NU             53.07              A5102        NU             29.60
       A4397         NU              5.41              A5105        NU             43.80
       A4398         NU             18.11              A5112        NU             43.79
       A4399         NU             16.08              A5113        NU              5.96
       A4400         NU             54.45              A5114        NU             10.57
       A4402         NU              1.86              A5120        NU              0.33
       A4404         NU              2.22              A5121        NU              8.20
       A4405         NU              4.46              A5122        NU             16.85
       A4406         NU              7.52              A5126        NU              1.42
       A4407         NU             11.48              A5131        NU             17.68
       A4408         NU             12.94              A5200        NU             14.39
       A4409         NU              8.16              A5500        NU             77.82
       A4410         NU             11.85              A5501        NU            233.41
       A4411         NU              6.69              A5503        NU             34.61
       A4412         NU              3.57              A5504        NU             34.61
       A4413         NU              7.22              A5505        NU             34.61
       A4414         NU              6.46              A5506        NU             34.97
       A4415         NU              7.87              A5507        NU             34.61


900-1101-0409                               DME - 21                                  www.bcbsfl.com
                             Durable Medical Equipment
                TENS and Supplies                         Wheel Chairs and Accessories
       Code         Modifier   Allowance                 Code      Modifier    Allowance
       A4595          NU              37.77              E0144        NU             413.09
       A6412          NU               0.46              E0144        RR              41.33
       A6443          NU               0.39              E0147        NU             745.64
       A6446          NU               0.54              E0147        RR              74.56
       E0720          NU             476.83              E0148        NU             164.81
       E0720          RR              55.31              E0148        RR              16.50
       E0730          NU             480.70              E0149        NU             289.54
       E0730          RR              48.07              E0149        RR              28.95
       E0731          NU             462.70              E0153        NU              76.49
       E0731          RR             423.36              E0153        RR               8.64
       E0744          NU           1,010.93              E0154        NU              77.74
       E0744          RR             118.79              E0154        RR               9.60
       E0745          NU             864.71              E0155        NU              37.70
       E0745          RR             116.11              E0155        RR               4.24
                                                         E0156        NU              29.15
                                                         E0156        RR               3.73
                                                         E0157        NU              90.32
                                                         E0157        RR               9.91
                                                         E0158        NU              35.48
                                                         E0158        RR               3.92
                                                         E0159        NU              23.18
                                                         E0159        RR               2.33
                                                         E0160        NU              36.45
                                                         E0160        RR               4.77
                                                         E0161        NU              34.03
                                                         E0161        RR               4.28
                                                         E0162        NU             189.00
                                                         E0162        RR              19.83
                                                         E0163        NU             139.08
                                                         E0163        RR              26.97
                                                         E0165        NU             179.54
                                                         E0165        RR              24.11
                                                         E0167        NU              13.26
                                                         E0167        RR               1.39
                                                         E0168        NU             195.77
                                                         E0168        RR              19.57
                                                         E0175        NU              85.92
                                                         E0175        RR               8.58
                                                         E0181        NU             243.21
                                                         E0181        RR              28.58
                                                         E0182        NU             245.64
                                                         E0182        RR              28.87
                                                         E0950        NU             114.62
                                                         E0950        RR              11.48
                                                         E0951        NU              24.62
                                                         E0951        RR               2.54
                                                         E0952        NU              24.43
                                                         E0952        RR               2.54
                                                         E0955        NU             262.27
                                                         E0955        RR              26.25


900-1101-0409                                 DME - 22                                   www.bcbsfl.com
                           Durable Medical Equipment
        Wheel Chairs and Accessories                    Wheel Chairs and Accessories
       Code      Modifier    Allowance                 Code      Modifier    Allowance
       E0956        NU             127.88              E0995        NU              33.52
       E0956        RR              12.81              E0995        RR               3.35
       E0957        NU             178.92              E1002        NU           5,335.41
       E0957        RR              17.88              E1002        RR             533.58
       E0958        NU             454.16              E1003        NU           5,696.39
       E0958        RR              50.23              E1003        RR             569.65
       E0959        NU              48.76              E1004        NU           6,316.14
       E0959        RR               4.90              E1004        RR             631.61
       E0960        NU             118.02              E1005        NU           6,836.71
       E0960        RR              11.80              E1005        RR             683.67
       E0961        NU              32.79              E1006        NU           8,374.34
       E0961        RR               3.42              E1006        RR             837.41
       E0966        NU              84.86              E1007        NU          11,339.17
       E0966        RR               8.49              E1007        RR           1,133.92
       E0967        NU              85.17              E1008        NU          11,340.19
       E0967        RR               8.51              E1008        RR           1,134.02
       E0968        NU             197.95              E1009        NU               0.00
       E0969        NU             203.18              E1009        RR               0.00
       E0969        RR              20.12              E1009        UE               0.00
       E0970        NU              58.28              E1010        NU           1,483.72
       E0970        RR               5.20              E1010        RR             148.38
       E0971        NU              56.29              E1011        NU               0.00
       E0971        RR               5.63              E1011        RR               0.00
       E0973        NU             126.77              E1011         UE              0.00
       E0973        RR              12.08              E1014        NU             473.66
       E0974        NU              86.46              E1014        RR              47.38
       E0974        RR               9.16              E1015        NU             148.79
       E0978        NU              47.09              E1015        RR              14.86
       E0978        RR               4.72              E1016        NU             170.33
       E0980        NU              36.45              E1016        RR              17.04
       E0980        RR               3.64              E1017        NU             552.00
       E0981        NU              61.16              E1018        NU             552.00
       E0981        RR               6.22              E1020        NU             315.76
       E0982        NU              66.85              E1020        RR              31.55
       E0982        RR               6.68              E1028        NU             267.93
       E0983        NU             926.38              E1028        RR              26.79
       E0983        RR             268.27              E1029        NU             479.37
       E0984        NU           2,478.41              E1029        RR              47.93
       E0984        RR             204.17              E1030        NU           1,511.58
       E0985        NU             263.14              E1030        RR             151.17
       E0985        RR              26.33              E1031        NU             473.95
       E0986        NU           6,309.90              E1031        RR              55.68
       E0986        RR             630.99              E1037        RR             140.25
       E0990        NU             152.32              E1050        NU           1,015.40
       E0990        RR              16.85              E1050        RR             112.29
       E0990         UE            113.44              E1060        NU           1,257.04
       E0992        NU             118.07              E1060        RR             139.01
       E0992        RR              11.81              E1070        NU           1,091.99
       E0994        NU              22.87              E1070        RR             120.76
       E0994        RR               2.30              E1083        NU             785.08


900-1101-0409                               DME - 23                                   www.bcbsfl.com
                           Durable Medical Equipment
        Wheel Chairs and Accessories                    Wheel Chairs and Accessories
       Code      Modifier    Allowance                 Code      Modifier    Allowance
       E1083        RR              86.82              E1222        RR              74.74
       E1084        NU             978.14              E1223        NU             694.64
       E1084        RR             108.18              E1223        RR              81.61
       E1085        NU             898.08              E1224        NU             761.54
       E1085        RR              89.85              E1224        RR              89.48
       E1086        NU           1,093.82              E1225        NU             424.16
       E1086        RR              95.81              E1225        RR              49.83
       E1087        NU           1,187.13              E1226        NU             601.64
       E1087        RR             139.49              E1226        RR              61.93
       E1088        NU           1,503.23              E1227        NU             359.97
       E1088        RR             166.23              E1227        RR              36.00
       E1089        NU           1,451.77              E1228        NU             279.45
       E1089        RR             145.22              E1228        RR              30.90
       E1090        NU           1,496.46              E1230        NU           2,493.89
       E1090        RR             139.82              E1230        RR             248.23
       E1092        NU           1,281.33              E1231        NU           6,683.34
       E1092        RR             141.70              E1231        RR             668.33
       E1093        NU           1,101.93              E1232        NU           2,773.95
       E1093        RR             121.85              E1232        RR             277.41
       E1100        NU           1,035.00              E1233        NU           2,874.25
       E1100        RR             114.47              E1233        RR             287.43
       E1110        NU           1,013.61              E1234        NU           2,502.23
       E1110        RR             112.10              E1234        RR             250.24
       E1130        NU             575.57              E1235        NU           2,409.45
       E1130        RR              55.21              E1235        RR             240.96
       E1140        NU             791.66              E1236        NU           2,125.77
       E1140        RR              79.96              E1236        RR             212.58
       E1150        NU             814.34              E1237        NU           2,144.34
       E1150        RR              90.05              E1237        RR             214.42
       E1160        NU             628.31              E1238        NU           1,611.16
       E1160        RR              69.50              E1238        RR             166.62
       E1161        NU           3,069.29              E1240        NU           1,027.13
       E1161        RR             306.93              E1240        RR             113.60
       E1170        NU             838.05              E1250        NU             886.42
       E1170        RR              98.48              E1250        RR              78.94
       E1171        NU             752.16              E1260        NU           1,036.01
       E1171        RR              88.38              E1260        RR              99.26
       E1172        NU             919.19              E1270        NU             740.78
       E1172        RR             108.00              E1270        RR              87.04
       E1180        NU             950.99              E1280        NU           1,308.65
       E1180        RR             111.74              E1280        RR             144.73
       E1190        NU           1,098.59              E1285        NU           1,335.21
       E1190        RR             129.09              E1285        RR             133.57
       E1195        NU           1,178.96              E1290        NU           1,381.35
       E1195        RR             138.52              E1290        RR             137.94
       E1200        NU             816.52              E1295        NU           1,139.88
       E1200        RR              95.94              E1295        RR             133.94
       E1221        NU             445.80              E1296        NU             637.79
       E1221        RR              52.38              E1296        RR              64.78
       E1222        NU             636.12              E1297        NU             135.70


900-1101-0409                               DME - 24                                   www.bcbsfl.com
                           Durable Medical Equipment
        Wheel Chairs and Accessories                    Wheel Chairs and Accessories
       Code      Modifier    Allowance                 Code      Modifier    Allowance
       E1297        RR              15.07              E2311        RR             307.34
       E2201        NU             483.98              E2321        NU           2,061.38
       E2201        RR              48.40              E2321        RR             206.14
       E2202        NU             614.85              E2322        NU           1,829.52
       E2202        RR              61.49              E2322        RR             182.95
       E2203        NU             621.43              E2323        NU              89.71
       E2203        RR              62.13              E2323        RR               8.97
       E2204        NU           1,055.15              E2324        NU              56.84
       E2204        RR             105.53              E2324        RR               5.67
       E2205        NU              42.38              E2325        NU           1,747.11
       E2206        NU              52.77              E2325        RR             174.74
       E2207        NU              56.24              E2326        NU             450.31
       E2208        NU             154.08              E2326        RR              45.06
       E2208        RR              15.29              E2327        NU           3,388.78
       E2208        UE             114.75              E2327        RR             338.89
       E2209        NU             139.01              E2328        NU           6,428.04
       E2209        RR              13.94              E2328        RR             642.79
       E2210        NU               8.50              E2329        NU           2,291.02
       E2211        NU              53.07              E2329        RR             229.09
       E2212        NU               7.63              E2330        NU           4,439.13
       E2213        NU              39.44              E2330        RR             443.90
       E2214        NU              39.69              E2331        NU               0.00
       E2215        NU              12.45              E2340        NU             464.87
       E2216        NU               0.00              E2340        RR              46.51
       E2217        NU               0.00              E2341        NU             697.36
       E2218        NU               0.00              E2341        RR              69.73
       E2219        NU              46.15              E2342        NU             581.12
       E2220        NU              37.00              E2342        RR              58.11
       E2221        NU              33.15              E2343        NU             929.80
       E2222        NU              27.32              E2343        RR              92.97
       E2223        NU               7.27              E2351        NU             906.26
       E2224        NU             127.21              E2351        RR              90.65
       E2225        NU              22.58              E2360        NU             145.73
       E2226        NU              49.21              E2360        RR              14.64
       E2230        NU               0.00              E2361        NU             180.92
       E2230        RR               0.00              E2361        RR              18.09
       E2230        UE               0.00              E2362        NU             119.31
       E2231        NU             207.83              E2362        RR              11.94
       E2231        RR              20.79              E2363        NU             241.28
       E2231        UE             155.87              E2363        RR              24.14
       E2291        NU               0.00              E2364        NU             145.73
       E2292        NU               0.00              E2364        RR              14.64
       E2293        NU               0.00              E2365        NU             145.51
       E2294        NU               0.00              E2365        RR              14.56
       E2295        NU               0.00              E2365         UE            109.13
       E2300        NU               0.00              E2366        NU             341.96
       E2301        NU               0.00              E2366        RR              34.28
       E2310        NU           1,518.04              E2367        NU             543.64
       E2310        RR             151.80              E2367        RR              54.37
       E2311        NU           3,073.33              E2368        NU             670.10


900-1101-0409                               DME - 25                                   www.bcbsfl.com
                           Durable Medical Equipment
        Wheel Chairs and Accessories                    Wheel Chairs and Accessories
       Code      Modifier    Allowance                 Code      Modifier    Allowance
       E2368        RR              67.03              E2605        NU             349.17
       E2368         UE            502.58              E2605        RR              34.93
       E2369        NU             583.66              E2606        NU             544.73
       E2369        RR              58.37              E2606        RR              54.50
       E2370        NU           1,041.44              E2607        NU             375.99
       E2370        RR             104.15              E2607        RR              37.61
       E2371        NU             195.55              E2608        NU             451.54
       E2372        NU               0.00              E2608        RR              45.14
       E2372        UE               0.00              E2609        NU           1,046.95
       E2373        NU           1,642.99              E2610        NU               0.00
       E2374        NU             720.46              E2611        NU             405.18
       E2375        NU           1,163.15              E2611        RR              40.52
       E2375        UE             872.36              E2612        NU             548.12
       E2376        NU           1,822.69              E2612        RR              54.81
       E2377        NU             659.56              E2613        NU             509.85
       E2381        NU             102.77              E2613        RR              50.99
       E2381        RR              10.29              E2614        NU             705.58
       E2382        NU              28.01              E2614        RR              70.57
       E2382        RR               2.79              E2615        RR              58.69
       E2382        UE              21.01              E2616        NU             789.46
       E2383        NU             204.90              E2616        RR              78.95
       E2383        RR              20.49              E2617        NU           1,136.58
       E2384        NU             109.16              E2619        NU              66.57
       E2384        RR              10.94              E2619        RR               6.65
       E2385        NU              66.78              E2620        NU             745.57
       E2385        RR               6.69              E2620        RR              74.55
       E2386        NU             203.05              E2621        NU             710.48
       E2386        RR              20.30              E2621        RR              71.04
       E2387        NU              87.60              K0001        NU             544.69
       E2387        RR               8.78              K0001        RR              58.62
       E2388        NU              68.42              K0002        NU             815.99
       E2389        NU              37.15              K0002        RR              87.84
       E2390        NU              58.11              K0003        NU             893.27
       E2391        NU              27.83              K0003        RR              96.16
       E2391        UE              20.87              K0004        NU           1,332.39
       E2392        NU              73.17              K0004        RR             143.42
       E2393        NU               0.00              K0005        NU           2,334.44
       E2394        NU             104.22              K0005        RR             233.43
       E2395        NU              74.08              K0006        NU           1,250.42
       E2396        NU              76.26              K0006        RR             134.61
       E2396        RR               8.17              K0007        NU           1,942.90
       E2399        NU               0.00              K0007        RR             209.15
       E2601        NU              79.34              K0010        NU           3,997.47
       E2601        RR               7.95              K0010        RR             457.21
       E2602        NU             154.89              K0011        NU           6,968.03
       E2602        RR              15.48              K0011        RR             612.22
       E2603        NU             196.64              K0012        NU           3,654.63
       E2603        RR              19.68              K0012        RR             375.55
       E2604        NU             244.41              K0014        NU               0.00
       E2604        RR              24.43              K0015        NU             229.44


900-1101-0409                               DME - 26                                   www.bcbsfl.com
                           Durable Medical Equipment
        Wheel Chairs and Accessories                    Wheel Chairs and Accessories
       Code      Modifier    Allowance                 Code      Modifier    Allowance
       K0015        RR              22.95              K0072        RR               8.29
       K0017        NU              64.54              K0073        NU              42.27
       K0017        RR               6.46              K0073        RR               4.25
       K0018        NU              36.05              K0077        NU              74.31
       K0018        RR               3.59              K0077        RR               7.42
       K0019        NU              20.64              K0098        NU              33.35
       K0019        RR               2.07              K0098        RR               3.34
       K0020        NU              58.66              K0105        NU             125.55
       K0020        RR               5.87              K0105        RR              12.54
       K0037        NU              60.82              K0108        NU               0.00
       K0037        RR               5.42              K0195        NU             132.05
       K0038        NU              30.64              K0195        RR              23.14
       K0038        RR               3.06              K0733        NU              38.14
       K0039        NU              68.03              K0733        RR               3.84
       K0039        RR               6.82              K0734        NU             418.55
       K0040        NU              94.28              K0734        RR              41.86
       K0040        RR               9.41              K0735        NU             532.58
       K0041        NU              66.82              K0735        RR              53.27
       K0041        RR               6.71              K0736        NU             421.98
       K0042        NU              46.00              K0736        RR              42.20
       K0042        RR               4.58              K0737        NU             534.20
       K0043        NU              24.66              K0737        RR              53.41
       K0043        RR               2.46              K0813        NU           3,254.61
       K0044        NU              21.02              K0813        RR             317.23
       K0044        RR               2.11              K0813         UE          2,440.96
       K0045        NU              71.50              K0814        NU           4,165.79
       K0045        RR               7.16              K0814        RR             418.86
       K0046        NU              24.66              K0814         UE          3,124.35
       K0046        RR               2.46              K0815        NU           4,743.89
       K0047        NU              96.57              K0815        RR             412.66
       K0047        RR               9.69              K0815        UE           3,557.93
       K0050        NU              41.04              K0816        NU           4,543.00
       K0050        RR               4.08              K0816        RR             440.55
       K0051        NU              66.43              K0816        UE           3,407.26
       K0051        RR               6.68              K0820        NU           3,476.12
       K0052        NU             116.72              K0820        RR             353.67
       K0052        RR              11.66              K0820        UE           2,607.10
       K0053        NU             128.81              K0821        NU           4,462.46
       K0053        RR              12.86              K0821        RR             434.95
       K0056        NU             120.09              K0821        UE           3,346.86
       K0056        RR              12.01              K0822        NU           5,407.42
       K0065        NU              56.14              K0822        RR             535.80
       K0065        RR               5.62              K0822        UE           4,055.54
       K0069        NU             126.17              K0823        NU           5,428.44
       K0069        RR              12.61              K0823        RR             475.48
       K0070        NU             231.27              K0823         UE          4,071.33
       K0070        RR              23.14              K0824        NU           6,533.36
       K0071        NU             137.94              K0824        RR             634.76
       K0071        RR              13.80              K0824         UE          4,900.02
       K0072        NU              83.03              K0825        NU           5,706.22


900-1101-0409                               DME - 27                                   www.bcbsfl.com
                           Durable Medical Equipment
        Wheel Chairs and Accessories                    Wheel Chairs and Accessories
       Code      Modifier    Allowance                 Code      Modifier    Allowance
       K0825        RR             504.80              K0849        NU           6,854.45
       K0825         UE          4,279.66              K0849        RR             487.89
       K0826        NU           8,458.01              K0849         UE          5,140.85
       K0826        RR             812.52              K0850        NU           8,283.42
       K0826         UE          6,343.50              K0850        RR             566.64
       K0827        NU           7,191.99              K0850         UE          6,212.58
       K0827        RR             699.43              K0851        NU           7,744.30
       K0827         UE          5,394.01              K0851        RR             616.53
       K0828        NU           9,319.95              K0851         UE          5,809.36
       K0828        RR             906.01              K0852        NU           9,555.23
       K0828         UE          6,989.96              K0852        RR             967.31
       K0829        NU           8,558.37              K0852         UE          7,166.42
       K0829        RR             855.83              K0853        NU           9,815.62
       K0829         UE          6,418.79              K0853        RR             962.61
       K0830        NU           5,280.57              K0853         UE          7,361.71
       K0830        RR             607.20              K0854        NU          13,003.57
       K0830         UE          3,960.43              K0854        RR             915.41
       K0831        NU           5,280.57              K0854         UE          9,752.68
       K0831        RR             583.11              K0855        NU          12,283.82
       K0831         UE          3,960.43              K0855        RR           1,228.38
       K0835        NU           5,574.95              K0855         UE          9,212.87
       K0835        RR             545.67              K0856        NU           7,652.58
       K0835         UE          4,181.22              K0856        RR             498.21
       K0836        NU           5,676.40              K0856         UE          5,739.45
       K0836        RR             544.60              K0857        NU           7,805.97
       K0836         UE          4,257.30              K0857        RR             555.49
       K0837        NU           6,533.36              K0857         UE          5,854.48
       K0837        RR             632.12              K0858        NU           9,494.52
       K0837         UE          4,900.02              K0858        RR             543.54
       K0838        NU           5,898.60              K0858         UE          7,120.90
       K0838        RR             517.50              K0859        NU           8,820.64
       K0838         UE          4,423.95              K0859        RR             882.07
       K0839        NU           8,458.01              K0859         UE          6,615.49
       K0839        RR             845.80              K0860        NU          13,564.13
       K0839         UE          6,343.50              K0860        RR           1,332.90
       K0840        NU          12,814.29              K0860         UE         10,173.10
       K0840        RR           1,108.98              K0861        NU           7,690.57
       K0840         UE          9,610.72              K0861        RR             756.20
       K0841        NU           5,826.29              K0861         UE          5,767.93
       K0841        RR             628.47              K0862        NU           9,494.52
       K0841         UE          4,369.71              K0862        RR             782.49
       K0842        NU           5,826.29              K0862         UE          7,120.90
       K0842        RR             628.47              K0863        NU          13,564.13
       K0842         UE          4,369.71              K0863        RR           1,356.42
       K0843        NU           7,014.86              K0863         UE         10,173.10
       K0843        RR             696.46              K0864        NU          16,141.47
       K0843         UE          5,261.14              K0864        RR           1,614.14
       K0848        NU           7,330.55              K0864         UE         12,106.12
       K0848        RR             491.85              K0898        NU               0.00
       K0848         UE          5,497.91              K0899        NU               0.00


900-1101-0409                               DME - 28                                   www.bcbsfl.com
                             Hearing Aid Dealer
  Code          Allowance     Code    Allowance
  92541              61.85    V5011         95.33
  92542              62.74    V5014        114.98
  92543              28.82    V5020         53.52
  92544              49.86    V5030        847.08
  92545              44.46    V5040        643.89
  92546              95.42    V5050        744.65
  92547               6.60    V5060        622.14
  92548             122.28    V5070        345.77
  92551              17.81    V5080        868.82
  92552              30.57    V5090        308.98
  92553              45.85    V5100      1,393.96
  92555              26.96    V5110        314.00
  92556              40.43    V5120      1,218.36
  92557              83.88    V5130      1,296.12
  92559              59.27    V5140      1,347.97
  92560              35.02    V5150      1,439.12
  92561              49.46    V5160        376.30
  92562              28.77    V5170      1,000.95
  92563              26.96    V5180        847.08
  92564              33.39    V5190        990.07
  92565              27.18    V5200        311.49
  92567              37.43    V5210      1,087.91
  92568              26.96    V5220      1,045.26
  92569              28.77    V5230      1,080.38
  92571              17.17    V5240        322.36
  92572               6.44    V5241        296.93
  92575              20.09    V5242      1,010.00
  92576              31.58    V5243        670.00
  92577              50.49    V5244      1,312.00
  92579              50.06    V5245      1,035.00
  92582              50.06    V5246      1,168.75
  92583              61.73    V5247      1,268.67
  92584             170.10    V5248      2,020.00
  92585             135.74    V5249      1,340.00
  92586              83.71    V5250      2,624.00
  92587             102.51    V5251      2,070.00
  92588             134.00    V5252      2,337.51
  92590              70.52    V5253      2,537.33
  92591             105.54    V5254      1,312.50
  92592              30.82    V5255      1,035.00
  92593              46.26    V5256        897.50
  92594              33.23    V5257        925.00
  92595              50.44    V5258      2,625.00
  92596              41.64    V5259      2,070.00
  92597             156.37    V5260      1,795.00
  92620              64.58    V5261      1,850.00
  92621              17.82    V5264         27.52
  S0618              96.00    V5275         44.00
  V5008              46.83
  V5010              61.04




900-1101-1108                         HAD - 1       www.bcbsfl.com
                        Independent Clinical Laboratory
       Autopsy                          Lab                    Lab
  Code     Allowance            Code      Allowance    Code      Allowance
  88000          0.00           80048          11.83   80412         460.50
  88005          0.00           80050          44.09   80414          72.16
  88007          0.00           80051           9.80   80415          78.08
  88012          0.00           80053          14.77   80416         184.38
  88014          0.00           80055          56.00   80417          61.46
  88016          0.00           80061          18.72   80418         809.76
  88020          0.00           80069          12.13   80420         100.64
  88025          0.00           80074          66.54   80422          64.38
  88027          0.00           80076          11.42   80424          66.56
  88028          0.00           80100          20.32   80426         207.40
  88029          0.00           80101          19.24   80428          93.16
  88036          0.00           80102          18.51   80430         109.60
  88037          0.00           80150          21.06   80432         177.43
  88040          0.00           80152          25.01   80434         141.30
  88045          0.00           80154          25.84   80435         143.85
  88099          0.00           80156          20.34   80436         127.36
                                80157          18.52   80438          70.41
                                80158          24.31   80439          93.88
                                80160          24.05   80440          81.24
                                80162          18.55   80500          21.69
                                80164          18.93   80502          67.93
                                80166          21.66   81000           4.43
                                80168          22.83   81001           4.43
                                80170          22.90   81002           3.57
                                80172          22.76   81003           3.14
                                80173          20.34   81005           3.03
                                80174          24.05   81007           3.59
                                80176          16.26   81015           4.02
                                80178           9.24   81020           5.15
                                80182          18.93   81025           8.84
                                80184          16.01   81050           4.19
                                80185          18.52   81099           0.00
                                80186          19.23   82000          17.31
                                80188          23.18   82003          28.28
                                80190          23.41   82009           6.31
                                80192          23.41   82010           9.99
                                80194          20.39   82013          15.61
                                80195          19.17   82016          19.37
                                80196           9.92   82017          23.57
                                80197          19.17   82024          53.97
                                80198          19.77   82030          18.08
                                80200          22.52   82040           5.73
                                80201          16.66   82042           2.46
                                80202          18.93   82043           2.46
                                80299          19.13   82044           6.39
                                80400          45.56   82045          47.43
                                80402         121.46   82055          15.10
                                80406         109.34   82075          16.84
                                80408         175.34   82085          13.56
                                80410         112.23   82088          56.94


900-1101-0409                            ICL - 1                    www.bcbsfl.com
                         Independent Clinical Laboratory
          Lab                            Lab                    Lab
  Code      Allowance            Code      Allowance    Code      Allowance
  82101          41.94           82365          17.30   82585          11.98
  82103          18.77           82370          17.51   82595           9.04
  82104          20.20           82373          24.35   82600          27.11
  82105          23.44           82374           6.83   82607          21.06
  82106          23.44           82375          17.22   82608          20.01
  82107          89.99           82376           7.94   82610          19.00
  82108          35.60           82378          26.51   82615          11.41
  82120           4.02           82379          23.57   82626          35.31
  82127          19.37           82380          12.89   82627          31.07
  82128          19.37           82382          24.02   82633          43.28
  82131          23.57           82383          35.01   82634          40.90
  82135          23.00           82384          33.28   82638          17.11
  82136          23.57           82387          29.07   82646          27.81
  82139          23.57           82390          15.01   82649          35.91
  82140          20.36           82397          19.74   82651          36.07
  82143           9.61           82415          17.70   82652          53.78
  82145          21.72           82435           6.42   82654          19.11
  82150           9.06           82436           4.55   82656          16.12
  82154          40.29           82438           6.83   82657          24.35
  82157          40.90           82441           8.38   82658          24.35
  82160          34.94           82465           6.08   82664          48.00
  82163          28.68           82480           9.93   82666          30.01
  82164          20.39           82482           8.31   82668          26.26
  82172          19.80           82485          20.02   82670          39.04
  82175          26.51           82486          24.35   82671          45.13
  82180          13.81           82487          20.02   82672          30.30
  82190          17.08           82488          20.02   82677          33.79
  82205          16.01           82489          20.02   82679          34.88
  82232          22.61           82491          24.35   82690          21.99
  82239          23.94           82492          24.35   82693          13.75
  82240          24.31           82495          28.34   82696          32.95
  82247           7.02           82507          38.85   82705           7.11
  82248           7.02           82520          21.17   82710          22.12
  82252           2.73           82523          26.11   82715          24.05
  82261          23.57           82525          17.34   82725          12.08
  82270           4.54           82528          31.45   82726          24.35
  82271           4.54           82530          23.35   82728          19.03
  82272           4.54           82533          22.78   82731          89.99
  82274          22.22           82540           6.48   82735          12.62
  82286           9.62           82541          24.35   82742          27.66
  82300          13.25           82542          24.35   82746          20.54
  82306          41.36           82543          24.35   82747           4.30
  82307          45.02           82544          24.35   82757          16.89
  82308          37.41           82550           9.10   82759          30.01
  82310           7.20           82552          18.71   82760          15.64
  82330          19.09           82553          13.00   82775          29.43
  82331           7.23           82554          13.00   82776          11.71
  82340           8.43           82565           7.16   82784          12.99
  82355          16.17           82570           7.23   82785          23.01
  82360          12.22           82575          13.20   82787           4.36


900-1101-0409                             ICL - 2                    www.bcbsfl.com
                         Independent Clinical Laboratory
          Lab                            Lab                    Lab
  Code      Allowance            Code      Allowance    Code      Allowance
  82800           4.88           83055           6.87   83718          11.44
  82803          27.04           83060           8.12   83719          16.26
  82805          39.65           83065           6.00   83721          13.33
  82810          12.20           83068          11.83   83727          24.02
  82820          13.96           83069           5.51   83735           9.36
  82926           7.61           83070           6.64   83775          10.30
  82928           7.32           83071           9.61   83785          34.36
  82938          24.72           83080          23.57   83788          24.35
  82941          24.64           83088          41.26   83789          24.35
  82943          19.97           83090          23.57   83805          24.63
  82945           5.48           83150          17.30   83825          22.72
  82946          21.06           83491          24.47   83835          23.67
  82947           5.48           83497          18.01   83840          22.81
  82948           4.43           83498          37.95   83857          15.01
  82950           6.64           83499          35.22   83858          18.72
  82951          17.99           83500          31.65   83864          27.82
  82952           5.48           83505          33.96   83866          13.76
  82953           6.63           83516          16.12   83872           8.19
  82955          13.55           83518          11.85   83873          24.04
  82960           8.12           83519          18.88   83874          18.04
  82962           3.27           83520          18.09   83876          13.62
  82963          30.01           83525          15.98   83880          47.43
  82965           7.28           83527          18.09   83883          19.00
  82975          22.13           83528          22.22   83885           7.94
  82977          10.06           83540           9.05   83887          33.09
  82978          19.91           83550          12.21   83890           3.56
  82979           9.62           83570          12.36   83891           3.56
  82980          24.31           83582          19.80   83892           3.56
  82985          21.06           83586          17.89   83893           3.56
  83001          25.97           83593          36.75   83894           3.56
  83002          25.88           83605          14.92   83896           3.56
  83003          23.29           83615           8.44   83897           3.56
  83008          23.45           83625          17.88   83898          23.42
  83009          94.11           83630          27.42   83900          46.84
  83010          17.58           83631          27.42   83901          23.42
  83012          24.02           83632          28.24   83902          15.17
  83013          94.11           83633           7.69   83903          23.42
  83014          10.98           83634          11.17   83904          23.42
  83015          26.31           83655          16.91   83905          23.42
  83018          30.68           83661          27.56   83906          23.42
  83020          17.99           83662          26.43   83907          18.66
  83021          24.35           83663          26.43   83908          23.42
  83026           3.30           83664          26.43   83909          23.42
  83030          11.56           83670          12.80   83912           3.56
  83033           6.50           83690           9.62   83913          18.66
  83036          13.56           83695          18.09   83914          23.42
  83037          21.06           83698          47.43   83915          15.58
  83045           4.88           83700          15.73   83916          27.42
  83050           5.86           83701          17.30   83918          21.19
  83051          10.21           83704          29.52   83919          21.19


900-1101-0409                             ICL - 3                    www.bcbsfl.com
                         Independent Clinical Laboratory
          Lab                            Lab                    Lab
  Code      Allowance            Code      Allowance    Code      Allowance
  83921          21.19           84165          15.01   84466          17.84
  83925          27.19           84166          24.92   84478           8.04
  83930           9.24           84181          23.80   84479           9.04
  83935           9.52           84182          25.15   84480          19.81
  83937          28.73           84202          10.67   84481          21.97
  83945          17.99           84203          10.67   84482          21.97
  83950          89.99           84206          18.72   84484          13.75
  83951          67.71           84207          26.00   84485          10.01
  83970          57.67           84210          15.17   84488          10.01
  83986           5.00           84220           7.28   84490          10.01
  83992          20.54           84228           7.94   84510          12.22
  83993          27.42           84233          89.99   84512           7.58
  84022          21.76           84234          90.64   84520           5.51
  84030           7.69           84235          73.12   84525           4.02
  84035           5.11           84238          51.09   84540           6.64
  84060          10.32           84244          30.73   84545           9.23
  84061          11.06           84252          17.81   84550           6.31
  84066          13.50           84255          35.67   84560           6.64
  84075           7.23           84260          21.19   84577          17.43
  84078          10.20           84270          11.17   84578           4.54
  84080          20.66           84275          10.28   84580           9.92
  84081          23.09           84285          32.90   84583           7.02
  84085           9.42           84295           6.72   84585          21.66
  84087          11.31           84300           6.79   84586          26.81
  84100           6.63           84302           6.79   84588          47.43
  84105           6.50           84305          27.55   84590          16.20
  84106           5.99           84307          21.61   84591          16.20
  84110          11.80           84311           9.77   84597           9.77
  84119          12.03           84315           3.50   84600          22.45
  84120          20.55           84375          12.22   84620          16.55
  84126          35.59           84376           7.69   84630          15.91
  84127          16.28           84377           7.69   84681          26.81
  84132           6.42           84378          11.17   84702          21.03
  84133           6.01           84379          11.17   84703          10.49
  84134          20.38           84392           6.64   84704          21.03
  84135          26.73           84402          35.57   84830          14.02
  84138          26.46           84403          36.08   84999           0.00
  84140          23.53           84425          12.22   85002           6.29
  84143          31.89           84430          16.26   85004           9.04
  84144          29.15           84432          22.44   85007           4.81
  84146          27.08           84436           9.61   85008           4.81
  84150          34.88           84437           7.94   85009           5.19
  84152          25.70           84439          12.60   85013           3.31
  84153          25.70           84442          20.66   85014           3.31
  84154          25.70           84443          23.47   85018           3.31
  84155           5.12           84445          24.31   85025          10.86
  84156           5.12           84446          19.81   85027           9.04
  84157           5.12           84449          21.05   85032           6.01
  84160           7.23           84450           7.22   85041           4.20
  84163          21.03           84460           7.40   85044           6.01


900-1101-0409                             ICL - 4                    www.bcbsfl.com
                         Independent Clinical Laboratory
          Lab                            Lab                    Lab
  Code      Allowance            Code      Allowance    Code      Allowance
  85045           5.59           85410          10.77   86141          18.09
  85046           7.80           85415          13.25   86146          23.12
  85048           3.55           85420           9.13   86147          23.12
  85049           6.25           85421          14.23   86148          22.44
  85055           5.86           85441           5.88   86155          22.33
  85060          23.60           85445           9.52   86156           9.36
  85097         105.50           85460          10.81   86157          11.27
  85130          16.62           85461           9.26   86160          16.78
  85170           5.05           85475          12.40   86161          16.78
  85175           6.35           85520          13.25   86162          28.39
  85210           8.12           85525          13.25   86171          14.00
  85220          24.66           85530          13.25   86185          12.50
  85230          25.02           85536           9.04   86200          18.09
  85240          25.02           85540          12.02   86215          18.51
  85244          28.53           85547          12.02   86225          19.20
  85245          32.06           85549          26.21   86226          16.92
  85246          32.06           85555           9.34   86235          25.06
  85247          32.06           85557          18.66   86243          28.68
  85250          26.60           85576          30.01   86255          16.84
  85260          25.02           85597          25.12   86256          16.84
  85270          25.02           85610           5.49   86277          21.99
  85280          27.04           85611           5.51   86280          11.44
  85290          22.83           85612          13.37   86294          27.41
  85291          12.42           85613          13.37   86300          28.50
  85292           7.28           85635          13.76   86301          28.50
  85293           7.28           85651           4.96   86304          28.50
  85300           8.12           85652           3.77   86308           7.23
  85301          15.11           85660           7.71   86309           9.04
  85302          16.80           85670           8.07   86310          10.30
  85303          19.32           85675           6.50   86316          28.50
  85305          16.20           85705          11.17   86317          20.95
  85306          21.41           85730           8.38   86318          18.09
  85307          21.41           85732           9.04   86320          31.32
  85335          17.99           85810          16.32   86325          31.24
  85337          14.56           85999           0.00   86327          31.70
  85345           6.01           86000           9.75   86329          19.62
  85347           5.95           86001           7.30   86331          16.75
  85348           5.20           86003           7.30   86332          34.05
  85360          11.17           86005          11.14   86334          31.21
  85362           9.62           86021          21.03   86335          41.00
  85366          12.03           86022          25.66   86336          21.77
  85370          14.83           86023          17.40   86337          29.92
  85378           9.97           86038          16.89   86340          21.06
  85379          14.22           86039          15.60   86341          27.65
  85380          14.22           86060          10.20   86343          17.41
  85384          11.87           86063           8.07   86344          11.16
  85385          11.87           86077          50.24   86353          68.49
  85390           6.63           86078          52.23   86355          52.70
  85397          24.13           86079          51.83   86356           5.86
  85400          12.36           86140           7.23   86357          52.70


900-1101-0409                             ICL - 5                    www.bcbsfl.com
                         Independent Clinical Laboratory
          Lab                            Lab                    Lab
  Code      Allowance            Code      Allowance    Code      Allowance
  86359          52.70           86666           8.11   86784          11.31
  86360           9.77           86668          14.53   86787          18.00
  86361           5.86           86671          17.13   86788          23.54
  86367          52.70           86674          19.64   86789          20.11
  86376          20.33           86677          20.28   86790          18.00
  86378          27.51           86682          18.17   86793          18.33
  86382          23.62           86684          22.14   86800          22.22
  86384          15.91           86687          11.72   86803          19.94
  86403          14.24           86688          19.57   86804          21.64
  86406          14.87           86689          27.05   86805          73.05
  86430           7.93           86692          23.98   86806          66.49
  86431           7.93           86694          20.11   86807          55.29
  86480          86.59           86695          18.43   86808          41.47
  86485          18.95           86696          27.05   86812          36.06
  86486           0.00           86698          17.46   86813          81.02
  86490          11.62           86701          12.41   86816          38.92
  86510          12.81           86702          18.88   86817          89.95
  86580          10.83           86703          19.17   86821          78.88
  86590          12.22           86704          16.84   86822          51.07
  86592           5.96           86705          16.44   86849           0.00
  86593           6.16           86706          15.01   86850          17.87
  86602           8.11           86707          16.16   86860          21.45
  86603          17.98           86708          17.31   86870          33.36
  86606          21.03           86709          15.73   86880           7.50
  86609          18.00           86710          18.94   86885           7.99
  86611           8.11           86713          21.39   86886           7.23
  86612          18.03           86717          17.12   86890          72.28
  86615          18.43           86720          18.43   86891         112.80
  86617          21.64           86723          18.43   86900           4.17
  86618          21.05           86727          17.98   86901           4.17
  86619          18.69           86729          16.69   86903           8.46
  86622          12.48           86732          18.43   86904          13.28
  86625          18.33           86735          18.23   86905           5.34
  86628          11.31           86738          18.51   86906          10.83
  86631          16.52           86741          18.43   86910          19.86
  86632          17.74           86744          18.43   86911          17.08
  86635          16.03           86747          21.00   86920          29.79
  86638          16.94           86750          13.00   86921          24.23
  86641          15.86           86753          17.32   86922          27.01
  86644          20.11           86756          18.01   86927          11.91
  86645          23.54           86757          27.05   86930          90.16
  86648          21.25           86759          18.43   86931          67.52
  86651          18.43           86762          20.11   86932          90.16
  86652          18.43           86765          18.00   86940          11.46
  86653          18.43           86768          16.26   86941          13.27
  86654          18.43           86771          18.33   86945          25.42
  86658          18.20           86774          20.68   86950          56.00
  86663          18.33           86777          20.11   86965          22.64
  86664          21.38           86778          20.12   86970          17.87
  86665          25.35           86781          18.50   86971          17.87


900-1101-0409                             ICL - 6                    www.bcbsfl.com
                         Independent Clinical Laboratory
          Lab                            Lab                    Lab
  Code      Allowance            Code      Allowance    Code      Allowance
  86972          28.99           87188           8.12   87341          14.43
  86975          24.23           87190           7.90   87350          16.10
  86976          27.01           87197          20.99   87380          22.94
  86977          24.23           87205           5.96   87385          16.76
  86978          24.23           87206           7.50   87390          15.61
  86985          17.87           87207           8.37   87391          15.61
  86999           0.00           87209          25.11   87400          16.76
  87001          18.47           87210           5.96   87420          16.76
  87003          23.52           87220           5.96   87425          16.76
  87015           9.33           87230          27.59   87427          16.76
  87040          14.42           87250          27.32   87430          16.76
  87045          13.18           87252          36.42   87449          16.76
  87046          13.18           87253          28.22   87450          13.39
  87070          12.03           87254          27.32   87451          13.39
  87071          13.18           87255          47.31   87470          17.79
  87073          13.18           87260          16.76   87471          41.65
  87075          13.22           87265          16.76   87472          59.85
  87076          11.29           87267          16.76   87475          17.79
  87077          11.29           87269          16.76   87476          41.65
  87081           9.26           87270          16.76   87477          59.85
  87084          12.03           87271          16.76   87480          17.79
  87086          11.28           87272          16.76   87481          41.65
  87088          11.31           87273          16.76   87482          58.33
  87101          10.77           87274          16.76   87485          17.79
  87102          11.74           87275          16.76   87486          41.65
  87103          12.60           87276          16.76   87487          59.85
  87106          14.42           87277          16.76   87490          17.79
  87107          14.42           87278          16.76   87491          41.65
  87109          21.50           87279          16.76   87492          48.84
  87110          23.73           87280          16.76   87495          17.79
  87116          15.10           87281          16.76   87496          41.65
  87118          15.29           87283          16.76   87497          59.85
  87140           7.79           87285          16.76   87498          41.65
  87143          17.51           87290          16.76   87500          41.65
  87147           7.23           87299          16.76   87510          17.79
  87149          17.79           87300          16.76   87511          41.65
  87152           7.31           87301          16.76   87512          58.33
  87158           7.31           87305          16.76   87515          17.79
  87164          15.01           87320          16.76   87516          41.65
  87166          15.78           87324          16.76   87517          59.85
  87168           5.96           87327          16.76   87520          17.79
  87169           5.96           87328          16.76   87521          41.65
  87172           5.96           87329          16.76   87522          59.85
  87176           8.22           87332          16.76   87525          17.79
  87177          12.43           87335          16.76   87526          41.65
  87181           1.17           87336          16.76   87527          58.33
  87184           9.63           87337          16.76   87528          17.79
  87185           1.17           87338          17.19   87529          41.65
  87186          12.08           87339          16.76   87530          59.85
  87187          14.48           87340          14.43   87531          17.79


900-1101-0409                             ICL - 7                    www.bcbsfl.com
                         Independent Clinical Laboratory
          Lab                            Lab                    Lab
  Code      Allowance            Code      Allowance    Code      Allowance
  87532          41.65           87899          16.76   88245         190.23
  87533          58.33           87900         182.11   88248         241.96
  87534          17.79           87901         359.69   88249         241.96
  87535          41.65           87902         359.69   88261         246.93
  87536          98.47           87903         682.72   88262         174.14
  87537          17.79           87904          36.42   88263         190.23
  87538          41.65           87905           9.92   88264         174.14
  87539          59.85           87999           0.00   88267         251.17
  87540          17.79           88104          59.27   88269         190.23
  87541          41.65           88106          77.54   88271          20.22
  87542          58.33           88107          95.93   88272          35.39
  87550          17.79           88108          72.77   88273          44.89
  87551          41.65           88112         117.03   88274          48.63
  87552          59.85           88125          21.13   88275          56.11
  87555          17.79           88130          21.02   88280          35.07
  87556          41.65           88140          11.17   88283          95.84
  87557          59.85           88141          24.43   88285          26.54
  87560          17.79           88142          28.21   88289          40.56
  87561          41.65           88143          28.21   88291          27.45
  87562          59.85           88147          14.76   88299           0.00
  87580          17.79           88148          14.76   88300          23.81
  87581          41.65           88150          14.76   88302          50.77
  87582          58.33           88152          14.76   88304          64.53
  87590          17.79           88153          14.76   88305         109.56
  87591          41.65           88154          14.76   88307         202.56
  87592          59.85           88155           8.37   88309         300.37
  87620          17.79           88160          54.20   88311          19.16
  87621          41.65           88161          59.76   88312          91.01
  87622          58.33           88162          71.70   88313          66.43
  87640          41.65           88164          14.76   88314          99.57
  87641          41.65           88165          14.76   88318          95.58
  87650          17.79           88166          14.76   88319         155.02
  87651          41.65           88167          14.76   88321          90.92
  87652          58.33           88172          54.03   88323         143.12
  87653          41.65           88173         139.88   88325         200.81
  87660          17.79           88174          29.39   88329          50.64
  87797          17.79           88175          34.70   88331          92.60
  87798          41.65           88182         110.31   88332          41.74
  87799          59.85           88184          65.24   88333          93.37
  87800          35.58           88185          35.45   88334          54.21
  87801          83.30           88187          64.56   88342          96.58
  87802          16.76           88188          79.90   88346          99.74
  87803          16.76           88189         104.03   88347          84.25
  87804          16.76           88230         162.77   88348         518.49
  87807          16.76           88233         196.63   88349         227.20
  87808          16.76           88235         205.74   88355         368.21
  87809          16.76           88237         176.47   88356         309.40
  87810          16.76           88239         206.12   88358          82.74
  87850          16.76           88240          14.11   88360         118.56
  87880          16.76           88241          14.11   88361         171.32


900-1101-0409                             ICL - 8                    www.bcbsfl.com
                         Independent Clinical Laboratory
          Lab                            Lab
  Code      Allowance            Code      Allowance
  88362         278.42           G0145          34.70
  88365         137.30           G0147          14.76
  88367         225.67           G0148          14.76
  88368         175.47           G0306          10.86
  88371          31.05           G0307           9.04
  88372          31.79           G0328          22.22
  88384         100.00           G0394           4.54
  88385         414.79
  88386         428.68
  88400           7.02
  88720           5.28
  88740           5.28
  88741           5.28
  89050           6.61
  89051           7.70
  89055           5.96
  89060           9.99
  89100         165.19
  89105         160.14
  89125           6.03
  89130         136.80
  89132         117.70
  89135         174.46
  89136         129.18
  89140         164.68
  89141         167.57
  89160           5.15
  89190           6.64
  89225           4.67
  89230           5.66
  89235           7.69
  89240           0.00
  89300          12.45
  89310          12.03
  89320          16.84
  89321          16.84
  89322          21.65
  89325          14.91
  89329          29.30
  89330          13.83
  89331          27.37
  G0027           9.09
  G0103          25.70
  G0123          28.21
  G0143          28.21
  G0144          29.39




900-1101-0409                             ICL - 9          www.bcbsfl.com
                  Independent Diagnostic Testing Center
   Advance Imaging           Advance Imaging         Advance Imaging
  Code      Allowance       Code      Allowance     Code      Allowance
  70336          639.94     72156        1,305.79   78492        1,801.64
  70450          269.64     72157        1,305.38   78608        2,086.26
  70460          368.86     72158        1,355.02   78609        2,255.64
  70470          451.18     72159          759.66   78811        2,280.48
  70480          291.02     72191          723.92   78812        2,724.11
  70481          385.45     72192          339.20   78813        3,088.74
  70482          451.36     72193          386.09   78814        2,965.99
  70486          286.60     72194          437.12   78815        3,383.39
  70487          380.67     72195          595.43   78816        3,400.04
  70488          460.25     72196          796.46
  70490          330.21     72197        1,292.17
  70491          344.87     72198          700.02
  70492          462.15     73200          322.31
  70496          667.49     73201          373.12
  70498          667.49     73202          465.19
  70540          610.46     73206          672.82
  70542          784.41     73218          584.64
  70543        1,246.86     73219          784.87
  70544          597.84     73220        1,276.19
  70545          659.39     73221          653.43
  70546        1,231.78     73222          723.12
  70547          570.86     73223        1,393.55
  70548          589.97     73225          693.09
  70549        1,037.28     73700          328.82
  70551          605.24     73701          383.43
  70552          814.48     73702          465.19
  70553        1,445.24     73706          678.57
  71250          373.12     73718          550.26
  71260          401.23     73719          749.68
  71270          491.99     73720        1,246.44
  71275          630.29     73721          604.25
  71550          665.49     73722          701.84
  71551          796.46     73723        1,393.55
  71552        1,387.19     73725          701.44
  71555          700.96     74150          333.46
  72125          383.43     74160          439.47
  72126          447.01     74170          531.35
  72127          543.19     74175          729.17
  72128          383.43     74181          595.43
  72129          447.01     74182          796.46
  72130          543.19     74183        1,258.67
  72131          343.06     74185          626.34
  72132          431.85     75635          933.26
  72133          543.19     75989          242.87
  72141          614.50     76010           38.50
  72142          824.36     76376          164.02
  72146          671.05     76377          244.68
  72147          823.90     76380          246.05
  72148          664.22     78459        2,754.56
  72149          814.94     78491        1,162.47


900-1101-0409                         IDTC - 1                       www.bcbsfl.com
                 Independent Diagnostic Testing Center
  General Diagnostic       General Diagnostic     General Diagnostic
  Code      Allowance      Code      Allowance    Code      Allowance
  31620         343.78     71120          47.72   73530          45.66
  36598         158.31     71130          51.51   73540          43.93
  37250         153.16     72010          83.43   73542         147.88
  70010         302.77     72020          31.87   73550          37.59
  70015         152.34     72040          46.31   73560          38.04
  70030          33.29     72050          60.30   73562          42.51
  70100          38.50     72052          74.17   73564          42.28
  70110          49.16     72069          39.95   73565          36.60
  70120          44.86     72070          43.54   73580         172.20
  70130          64.09     72072          47.67   73590          34.02
  70134          61.73     72074          62.60   73592          35.66
  70140          45.35     72080          49.62   73600          31.89
  70150          58.03     72090          47.83   73610          38.50
  70160          38.04     72100          45.03   73615         146.43
  70170          69.75     72110          68.34   73620          35.66
  70190          46.78     72114          76.73   73630          38.50
  70200          59.46     72120          61.66   73650          34.71
  70210          39.71     72170          32.45   73660          27.24
  70220          57.55     72190          49.14   74000          34.45
  70240          34.25     72200          38.04   74010          45.85
  70250          43.57     72202          45.35   74020          45.27
  70300          21.89     72220          37.59   74022          59.49
  70310          33.76     72240         306.14   74190          99.87
  70320          56.11     72255         282.88   74210          85.75
  70328          37.08     72265         265.79   74220          91.94
  70330          59.92     72270         404.89   74240         121.96
  70332         146.55     72285         510.75   74241         123.38
  70350          31.88     72295         462.83   74245         184.70
  70355          43.93     73000          37.07   74246         132.11
  70360          33.29     73010          38.04   74247         134.82
  70370          88.55     73020          34.23   74249         194.50
  70373         122.97     73030          38.01   74250          98.93
  70380          46.75     73040         145.61   74251         114.06
  70390         119.15     73050          48.65   74260         110.15
  71010          30.43     73060          42.03   74270         135.77
  71015          40.42     73070          32.74   74280         182.37
  71020          42.28     73080          42.03   74290          59.49
  71021          56.62     73085         146.09   74291          35.21
  71022          59.01     73090          37.07   74305          69.35
  71023          66.14     73092          35.66   74320         199.37
  71030          61.37     73100          31.89   74327         139.56
  71034         105.88     73110          34.45   74328         210.21
  71035          38.50     73115         118.90   74329         134.13
  71040         114.81     73120          35.66   74330         223.44
  71060         164.39     73130          34.45   74340         171.85
  71090         125.87     73140          27.24   74350         214.02
  71100          44.89     73500          35.66   74355         186.51
  71101          52.96     73510          39.73   74360         199.83
  71110          58.99     73520          52.48   74400         121.11
  71111          67.86     73525         146.43   74410         134.36


900-1101-0409                       IDTC - 2                      www.bcbsfl.com
                 Independent Diagnostic Testing Center
  General Diagnostic       General Diagnostic      General Diagnostic
  Code      Allowance      Code      Allowance     Code      Allowance
  74415         140.86     75822          147.94   76705         101.45
  74420         160.38     75825          728.79   76770         151.87
  74425          92.22     75827          727.15   76775         101.03
  74430          76.25     75831          727.98   76800         147.96
  74440          83.86     75833          752.86   76801         176.36
  74445         136.15     75840          729.27   76802         116.18
  74450          98.23     75842          750.75   76805         176.36
  74455         105.54     75860          727.28   76810         133.89
  74470         100.85     75870          728.11   76811         334.46
  74475         246.97     75872          734.49   76812         206.08
  74480         246.97     75880           96.68   76815         118.14
  74485         199.71     75885          747.07   76816         116.51
  74710          77.69     75887          747.07   76817         127.47
  74740          93.66     75889          727.15   76818         157.13
  74742         117.65     75891          727.15   76819         136.88
  74775         117.67     75893          686.98   76820         121.34
  75600         685.07     75894        1,338.03   76821         134.69
  75605         728.57     75896        1,173.65   76825         216.70
  75625         728.44     75898          165.31   76826          93.58
  75630         802.87     75945          264.82   76827         130.50
  75650         751.22     75946          145.61   76828          98.70
  75658         741.66     75960          826.18   76830         113.13
  75660         739.43     75980          376.62   76831         128.81
  75662         763.29     75982          419.62   76856         126.43
  75665         741.87     75984          149.49   76857         111.24
  75671         762.21     75992          851.98   76870         123.09
  75676         740.25     75993          250.05   76872         150.90
  75680         762.21     75994          902.05   76873         218.08
  75685         738.96     75995        1,069.43   76880         101.45
  75705         800.51     75996          244.97   76885         129.29
  75710         729.73     76080           90.57   76886         115.30
  75716         739.77     76098           28.95   76930         125.61
  75722         728.57     76100          104.05   76932         125.61
  75724         752.91     76101          112.90   76936         463.36
  75726         727.15     76102          130.50   76937          47.67
  75731         727.98     76120           80.54   76940         247.35
  75733         739.43     76125           58.99   76941         171.01
  75736         728.44     76506          120.13   76942         186.51
  75741         738.96     76510          218.16   76945         123.85
  75743         761.73     76511          168.60   76946         106.52
  75746         727.64     76512          160.77   76948         106.04
  75756         730.13     76513          127.02   76950         106.89
  75774         675.53     76514           15.92   76965         379.14
  75790         194.22     76516          101.45   76970          81.50
  75801         338.62     76519          105.71   76975         135.35
  75803         358.62     76529          100.26   76999            0.00
  75805         372.08     76536           99.01   78070         251.44
  75807         391.82     76604          104.17   93875         126.06
  75810         727.15     76645           90.57   93886         390.36
  75820          96.68     76700          140.89   93888         256.85


900-1101-0409                        IDTC - 3                       www.bcbsfl.com
                 Independent Diagnostic Testing Center
    Mammography                Medicine              Medicine
  Code   Allowance         Code     Allowance    Code     Allowance
  77051        27.88       93317        315.76   94260         37.75
  77052        27.88       93318        383.04   94350         52.48
  77053       133.88       93320        104.48   94360         51.27
  77054       183.29       93321         69.88   94370         48.96
  77055       110.54       93325        147.46   94375         45.67
  77056       136.68       93350        196.24   94400         66.23
  77057       130.35       93720         49.81   94450         62.63
  G0202       151.33       93721         38.49   94620        159.52
  G0204       182.62       93722          9.54   94621        185.60
  G0206       147.78       93724        544.13   94640         12.62
                           93727         36.00   94642         31.89
      Medicine             93731         56.84   94660         59.13
  Code     Allowance       93732         90.44   94662         41.87
  90772          19.62     93733         51.68   94664         16.04
  91110       1,239.49     93734         44.30   94667         24.15
  92081          63.33     93735         74.40   94668         19.30
  92585         135.74     93736         45.54   94680        106.63
  92586          83.71     93741         90.37   94681        139.88
  93000          31.06     93742         98.01   94690         93.45
  93005          22.92     93743        108.49   94720         59.96
  93012         299.95     93744        116.48   94725        161.20
  93015         125.31     93784         79.14   94750         78.48
  93016          27.93     93880        324.04   94760          3.52
  93017          88.45     93882        206.40   94761          7.34
  93018          18.23     93922        144.46   94762         25.59
  93024         140.09     93923        209.25   94770         49.18
  93040          15.02     93924        264.67   94772        233.07
  93041           7.91     93925        381.27   95251         29.91
  93224         193.02     93926        208.26   95813        337.12
  93225          65.18     93930        309.50   95816        240.74
  93226         115.03     93931        201.97   95819        184.51
  93230         206.32     93965        140.74   95822        285.30
  93231          80.88     93970        285.34   95827        195.42
  93232         114.21     93971        193.55   95830        207.57
  93235         140.29     93975        483.79   95831         32.20
  93236         135.83     93976        291.80   95832         25.15
  93268         337.39     93978        250.55   95833         43.44
  93270          58.32     93979        195.43   95834         51.35
  93271         268.38     93980        229.40   95851         20.65
  93272          31.77     93981        184.23   95852         14.74
  93278          80.89     93990        222.42   95857         46.64
  93303         290.06     94010         42.29   95860        118.86
  93304         153.64     94014         63.31   95861        151.05
  93307         237.02     94015         24.19   95863        184.10
  93308         139.33     94060         71.17   95864        238.26
  93312         352.18     94070         78.12   95867         87.54
  93313          50.79     94150         27.21   95868        121.91
  93314         288.30     94200         28.53   95869         38.49
  93315         470.41     94240         48.57   95870         38.49
  93316          51.31     94250         37.17   95872        140.62


900-1101-0409                       IDTC - 4                    www.bcbsfl.com
                 Independent Diagnostic Testing Center
      Medicine              Nuclear Medicine        Nuclear Medicine
  Code     Allowance       Code      Allowance     Code      Allowance
  95875         130.25     76977           47.03   78291          217.88
  95900          74.25     78000           63.53   78299            0.00
  95903          81.61     78001           85.21   78300          171.28
  95904          63.63     78003           72.60   78305          245.37
  95921          81.57     78006          139.88   78306          278.60
  95922          88.58     78010          122.00   78315          315.18
  95923         140.58     78011          155.36   78320          375.91
  95925          87.47     78015          178.89   78350           54.21
  95926          87.13     78016          234.75   78351           96.56
  95927          88.88     78018          339.64   78399            0.00
  95930         125.66     78020          113.69   78414           77.65
  95933          84.67     78075          331.18   78428          171.04
  95934          48.03     78099            0.00   78445          130.57
  95936          51.70     78102          143.72   78456          279.63
  95937          68.14     78103          214.95   78457          189.35
  95950         300.29     78104          264.48   78458          269.27
  95951       1,079.60     78120          106.91   78460          180.88
  95953         557.84     78121          170.91   78461          327.47
  95954         332.93     78122          268.42   78464          439.03
  95955         176.53     78130          188.31   78465          672.59
  95956         926.52     78135         294.75    78466         182.68
  95957         234.20     78140         244.64    78468         242.65
  95958         396.34     78185          150.13   78469          331.90
  95961         311.49     78190          372.71   78472          352.36
  95962         313.24     78191          419.48   78473          525.38
  95970          54.08     78195         292.72    78478         124.16
                           78199            0.00   78480          123.69
                           78201         152.51    78481         337.14
                           78202         182.24    78483         506.72
                           78205         353.62    78494         440.82
                           78206         354.35    78496         393.97
                           78215         183.63    78499            0.00
                           78216         217.71    78580         222.70
                           78220         224.62    78584         232.01
                           78223         219.98    78585         365.54
                           78230         144.48    78586         161.36
                           78231         199.35    78587         177.50
                           78232         214.33    78588         239.84
                           78258         197.85    78591         173.66
                           78261         259.22    78593         211.03
                           78262         265.36    78594         291.99
                           78264         265.89    78596         450.35
                           78267           12.41   78599            0.00
                           78268         106.39    78600         177.94
                           78270           95.19   78601         210.10
                           78271           99.44   78605         211.52
                           78272         138.84    78606         243.71
                           78278         317.52    78607         409.99
                           78282           65.65   78610         103.29
                           78290         203.70    78630         306.82


900-1101-0409                        IDTC - 5                       www.bcbsfl.com
                  Independent Diagnostic Testing Center
   Nuclear Medicine         Radiopharmaceutical     Special Diagnostic
  Code      Allowance        Code     Allowance         Services
  78635          173.76     A4642        1,001.62   Code      Allowance
  78645          215.34     A9500          148.91   93014          41.90
  78647          366.84     A9502          146.46   93230         451.30
  78650          281.14     A9503           40.68   93231         125.87
  78660          146.07     A9504          587.33   93233         386.45
  78699            0.00     A9505           52.84   93236         481.93
  78700          188.09     A9507        2,682.29   93268         261.94
  78701          216.23     A9508          606.48   93271         364.11
  78707          295.06     A9510           69.75   93272         325.40
  78710          350.28     A9512           28.52
  78725          119.63     A9516           79.56
  78730          100.15     A9517          212.67
  78740          149.28     A9521        1,089.78
  78761          213.52     A9528           50.50
  78799            0.00     A9552          568.58
  78800          221.27     A9700          201.83
  78801          272.74     Q0515            2.29
  78802          345.19     Q9954           11.60
  78803          413.60     Q9955           20.38
  78804          621.12
  78805          225.24     Special Diagnostic
  78806          391.84         Services
  78807          413.27     Code      Allowance
  78890           65.05     70371          166.34
  78891          142.52     72275          166.89
  78999            0.00     74230          102.73
  79005          244.96     74235          227.99
  79101          267.92     74283          268.29
  79200          271.11     74363          169.34
  79300         289.34      75809           72.21
  79403         371.89      75893          686.98
  79440         271.72      75900        1,169.81
  79999            0.00     75940          688.62
                            75954          786.16
   Mobile Radiology         75961          826.48
  Code      Allowance       75962          851.51
  Q0092           16.24     75964          458.29
  R0070          107.33     75966          904.07
  R0075          124.36     75968          457.96
  R0076           52.04     75970          652.55
                            75978          850.69
                            76000           79.00
                            76001          182.41
                            76150           21.51
                            78007          167.09
                            78110           63.06
                            78111          148.61
                            78708          312.11
                            78709          325.34
                            93012          299.95


900-1101-0409                         IDTC - 6                      www.bcbsfl.com
                  Independent Diagnostic Testing Center
    Surgical Codes            Surgical Codes
  Code       Allowance      Code       Allowance
  10022           158.30    62287          623.84
  19000           126.06    62290          447.96
  19001            31.49    62291          372.24
  19030           193.59
  19102           258.45     Temporary Codes
  19103           667.61    Code     Allowance
  19290           180.57    G0130          28.21
  19291            81.13    G0219       2,927.20
  19295           115.02
  20206           323.51
  20220           253.70
  20225         1,134.08
  20501           159.08
  20605            67.14
  20610            82.09
  23350           194.11
  24220           216.05
  25246           214.73
  27093           254.40
  27095           317.44
  27096           250.37
  27370           204.86
  27648           196.39
  32405           119.07
  36005           369.02
  36140           602.37
  38500           331.86
  38505           142.60
  42400           107.64
  47000           220.53
  47001           119.67
  47011           212.11
  48102           525.06
  49021           990.62
  49080           232.56
  49081           170.19
  49180           213.05
  50200           178.96
  50390           112.77
  50690           124.49
  51600           256.26
  51605           270.38
  51610           147.02
  55700           238.19
  58340           178.45
  58823         1,004.12
  59000           168.51
  59015           186.17
  60100           133.39
  62284           285.83


900-1101-0409                         IDTC - 7            www.bcbsfl.com
                          Rehabilitative Therapy
   General Therapy          Occupational Therapy       Physical Therapy
  Code      Allowance        Code      Allowance      Code      Allowance
  97010          25.43       97003          67.76     97001           63.33
  97012          25.11       97004          40.85     97002           33.56
  97014          19.51       97537          26.20
  97016          11.72                                 Speech Therapy
  97018            5.38     Orthotics & Prosthetics   Code     Allowance
  97022          12.35       Code       Allowance     92506        110.19
  97024            4.43      L1906           114.20   92507         52.25
  97026            4.12      L1920           290.53   92508         24.70
  97028            5.07      L1940           444.28   92526         69.98
  97032          13.30       L1960           460.63   92597        156.37
  97033          17.10       L1970           681.31
  97034          11.72       L2112           421.60
  97035          10.13       L2114           482.37
  97036          19.31       L3700            56.77
  97039            9.82      L3730           774.37
  97110          23.43       L3807           203.34
  97112          24.70       L3906           343.08
  97113          26.91       L3908            48.73
  97116          20.58       L3912            78.18
  97124          18.68       L3980           251.41
  97139          13.30       L3982           310.61
  97140          22.16       L4350            87.40
  97150          14.57       L4396           149.98
  97530          24.70
  97532          25.43
  97533          25.11
  97535          25.01
  97537          26.20
  97597          40.85
  97750          25.01
  G0283          19.51




900-1101-1108                            RT - 1                        www.bcbsfl.com
                             Sleep Center
  Code          Allowance
  95805             900.92
  95806             242.98
  95807             615.60
  95808             719.68
  95810             944.17
  95811             921.47
  95812             231.61




900-1101-1108                    SC - 1     www.bcbsfl.com
                             Urgent Care Center
  Code          Allowance
  99201              48.06
  99202              48.06
  99203              93.38
  99204             162.03
  99205             162.03
  99211              48.06
  99212              48.06
  99213              93.38
  99214             162.03
  99215             162.03




900-1101-1108                       UCC - 1       www.bcbsfl.com

								
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