"Appendix A: Geographic Modifier, by County" County Modifier County Modifier Alachua 1.0163 Lee 1.0132 Baker 0.9789 Leon 0.9703 Bay 0.8764 Levy 0.9266 Bradford 0.9266 Liberty 0.9266 Brevard 1.0149 Madison 0.9266 Broward 1.1195 Manatee 1.0447 Calhoun 0.9266 Marion 0.9331 Charlotte 0.9651 Martin 1.1815 Citrus 0.9266 Miami Dade 1.116 Clay 0.9789 Monroe 0.9266 Collier 1.0686 Nassau 0.9789 Columbia 0.9266 Okaloosa 0.9743 Desoto 0.9266 Okeechobee 0.9266 Dixie 0.9266 Orange 1.0096 Duval 0.9789 Osceola 1.0096 Escambia 0.9095 Palm Beach 1.0946 Flagler 0.9261 Pasco 0.9976 Franklin 0.9266 Pinellas 0.9976 Gadsden 0.9703 Polk 0.9307 Gilchrist 1.0163 Putnam 0.9266 Glades 0.9266 Santa Rosa 0.9095 Gulf 0.9266 Sarasota 1.0447 Hamilton 0.9266 Seminole 1.0096 Hardee 0.9266 St. Johns 0.9789 Hendry 0.9266 St. Lucie 1.1815 Hernando 0.9976 Sumter 0.9266 Highlands 0.9266 Suwannee 0.9266 Hillsborough 0.9976 Taylor 0.9266 Holmes 0.9266 Union 0.9266 Indian River 1.0024 Volusia 0.9626 Jackson 0.9266 Wakulla 0.9703 Jefferson 0.9703 Walton 0.9266 Lafayette 0.9266 Washington 0.9266 Lake 1.0096 Appendix B: Outpatient Hospital Services Subject to modification based on county of service. See Appendix A. CPT Base Rate CPT Base Rate CPT Base Rate 10060 $367.31 36600 $57.31 72100 $489.69 10061 $505.93 51702 $282.79 72110 $805.82 10120 $426.48 59025 $376.36 72125 "$2,396.98 " 11012 "$2,160.96 " 62284 $849.98 72128 "$2,199.13 " 11042 $941.72 62290 "$1,443.81 " 72131 "$2,405.64 " 11730 $478.79 64450 $579.60 72141 "$2,436.12 " 11740 $298.52 64510 "$1,248.62 " 72146 "$2,574.79 " 11760 $522.85 64622 "$2,034.44 " 72148 "$2,595.14 " 12001 $332.35 64623 "$1,013.48 " 72158 "$3,592.31 " 12002 $342.67 64626 "$1,614.76 " 72170 $400.84 12004 $322.55 64627 $600.45 72190 $342.58 12005 $539.56 65205 $279.61 72192 "$2,511.66 " 12011 $322.48 65220 $316.79 72193 "$2,925.31 " 12013 $343.90 65222 $312.22 72220 $462.22 12014 $305.53 70110 $550.73 73000 $391.40 12031 $377.35 70150 $537.51 73010 $414.26 12032 $377.13 70160 $398.11 73020 $328.43 12034 $381.58 70355 $287.98 73030 $455.17 12041 $432.11 70360 $331.42 73060 $408.92 12042 $403.42 70450 "$2,128.10 " 73070 $348.27 12051 $422.76 70480 "$2,389.52 " 73080 $439.57 12052 $398.03 70486 "$2,066.55 " 73090 $392.53 13121 $709.09 70551 "$2,551.71 " 73100 $359.21 13132 $944.93 70553 "$3,726.50 " 73110 $427.18 14040 $861.61 71010 $287.49 73120 $323.46 16000 $218.86 71020 $362.78 73130 $422.01 16020 $284.78 71100 $502.89 73140 $318.08 16025 $361.89 71101 $531.16 73200 "$1,673.64 " 20103 $961.07 71111 $604.68 73500 $345.45 20610 "$1,015.45 " 71120 $447.49 73510 $410.64 23350 $388.43 71250 "$2,193.50 " 73520 $627.95 23650 $503.86 71260 "$2,495.31 " 73550 $436.06 23655 "$1,156.79 " 71275 "$3,141.11 " 73560 $347.87 25246 $411.23 72020 $372.03 73562 $454.11 25605 $649.93 72040 $433.08 73564 $498.32 26765 "$1,680.44 " 72050 $667.91 73590 $421.89 26770 $459.34 72052 $672.71 73600 $322.04 27096 "$1,327.73 " 72070 $510.96 73610 $430.29 29260 $202.46 72072 $511.28 73620 $309.02 29515 $301.87 72074 $570.39 73630 $430.49 36000 $193.61 72080 $520.77 73650 $356.76 Appendix B: Outpatient Hospital Services Subject to modification based on county of service. See Appendix A. CPT Base Rate CPT Base Rate CPT Base Rate 73660 $311.65 82040 $143.80 84703 $122.10 73700 "$1,900.90 " 82055 $221.64 85007 $51.59 73721 "$2,460.05 " 82150 $165.92 85014 $52.71 74000 $362.71 82247 $172.12 85018 $52.97 74020 $603.98 82248 $68.34 85025 $158.30 74022 $592.30 82310 $45.19 85027 $124.32 74150 "$2,943.01 " 82330 $103.74 85378 $102.88 74160 "$2,917.80 " 82374 $42.65 85379 $167.89 74175 "$3,748.35 " 82375 $79.75 85384 $146.31 74176 "$4,058.53 " 82435 $49.33 85610 $101.79 74177 "$4,718.11 " 82550 $113.56 85651 $130.28 74178 "$5,098.00 " 82553 $188.78 85652 $73.06 76000 $589.71 82565 $53.41 85730 $128.58 76376 $498.85 82607 $140.47 86140 $111.34 76377 $832.53 82803 $294.33 86141 $131.15 76705 $585.01 82805 $288.61 86317 $40.10 76801 $632.40 82947 $53.51 86592 $65.99 76805 $941.09 82948 $20.00 86593 $79.75 76815 $447.52 82962 $24.80 86701 $140.74 76817 $467.95 83036 $124.64 86703 $139.39 76870 $729.28 83050 $42.32 86704 $90.41 78452 "$3,718.09 " 83605 $133.53 86705 $90.20 80047 $247.24 83615 $89.61 86706 $128.23 80048 $220.40 83690 $155.10 86709 $89.72 80051 $163.17 83735 $100.40 86803 $124.64 80053 $326.80 83874 $155.26 86850 $102.47 80061 $223.06 83880 $191.44 86900 $74.47 80074 $323.93 84075 $174.61 86901 $49.23 80076 $264.92 84100 $75.34 87040 $256.18 80100 $72.39 84132 $46.68 87070 $235.72 80101 $126.67 84155 $181.31 87075 $186.69 80104 $308.70 84295 $48.21 87077 $97.89 80196 $169.87 84436 $123.09 87081 $79.00 81000 $89.79 84439 $118.78 87086 $177.53 81001 $113.75 84443 $180.65 87088 $109.85 81002 $37.39 84450 $183.99 87186 $114.58 81003 $86.07 84460 $156.41 87205 $93.37 81015 $31.95 84484 $198.55 87340 $101.57 81025 $122.64 84520 $52.00 87522 $874.28 82003 $255.83 84550 $94.27 90471 $78.30 82009 $69.12 84702 $220.57 90472 $60.67 Appendix B: Outpatient Hospital Services Subject to modification based on county of service. See Appendix A. CPT Base Rate CPT Base Rate CPT Base Rate 90675 $751.34 95816 $758.43 99291 "$1,868.07 " 90701 $174.89 95819 $832.65 99401 $26.25 90703 $94.97 95860 $176.18 99402 $56.48 90714 $99.44 95903 $153.27 G0289 "$2,085.89 " 90715 $162.67 95904 $139.19 G0378 $101.71 90718 $105.60 95920 $559.48 G0380 $212.06 90732 $154.30 95990 $480.95 G0381 $545.78 90746 $105.18 96118 $274.15 G0382 $917.53 90806 $154.11 96152 $211.94 G0383 "$1,292.87 " 90901 $111.70 96360 $261.69 G0390 "$4,433.65 " 92134 $221.21 96361 $130.46 G0434 $285.67 92250 $279.89 96365 $304.19 92557 $216.06 96366 $118.10 92567 $95.64 96367 $148.66 93005 $258.29 96369 $69.41 93017 "$1,103.87 " 96370 $61.51 93041 $106.42 96372 $107.65 93225 $472.42 96374 $151.98 93226 $612.64 96375 $134.75 93306 "$1,861.02 " 96376 $126.62 93312 "$1,915.05 " 97597 $264.59 93325 $414.80 97602 $165.99 93350 "$1,881.67 " 99001 $62.88 93458 "$12,219.99 " 99070 $217.83 93798 $159.69 99144 $303.70 93880 "$1,054.23 " 99183 "$2,279.60 " 93926 $661.02 99201 $157.57 93970 "$1,006.00 " 99202 $170.61 93971 $746.39 99203 $262.54 93975 $852.57 99204 $281.01 93976 $661.67 99205 $234.75 94010 $188.55 99211 $137.11 94060 $492.15 99212 $149.31 94240 $345.11 99213 $139.80 94640 $100.05 99214 $184.96 94664 $86.33 99215 $177.64 94720 $325.39 99281 $229.26 94760 $50.95 99282 $353.33 94761 $109.13 99283 $620.73 94762 $248.70 99284 $904.69 95810 "$2,801.51 " 99285 "$1,334.93 " Appendix C: Scheduled Outpatient Surgical Services Subject to modification based on county of service. See Appendix A. CPT Base Rate CPT Base Rate CPT Base Rate 11012 "$2,370.99 " 29807 "$4,048.07 " 64476 $649.06 11042 $612.78 29822 "$3,423.64 " 64479 "$1,433.39 " 11043 $934.83 29823 "$3,859.65 " 64480 $320.22 11044 "$2,159.66 " 29824 "$2,909.30 " 64483 "$1,291.09 " 11045 $403.17 29826 "$3,887.00 " 64484 $504.09 11760 "$2,313.46 " 29827 "$3,915.75 " 64520 "$1,272.60 " 12001 $253.14 29828 "$3,234.15 " 64718 "$3,731.77 " 12002 $438.64 29846 "$4,624.60 " 64721 "$3,056.10 " 12011 $206.09 29848 "$2,463.66 " 64831 "$3,596.91 " 14040 "$2,628.81 " 29873 "$3,178.44 " 71010 $252.40 15271 "$1,047.23 " 29875 "$3,153.38 " 71020 $313.43 15340 $637.66 29876 "$2,962.15 " 72020 $222.06 16020 $254.42 29877 "$3,696.92 " 72040 $268.56 17250 $136.65 29879 "$2,218.68 " 72100 $278.31 20552 $403.26 29880 "$3,610.76 " 72275 $370.11 20553 $689.37 29881 "$3,933.98 " 73030 $365.55 20605 "$1,086.98 " 29888 "$5,880.17 " 73070 $270.18 20680 "$3,717.43 " 36569 "$1,150.80 " 73080 $370.91 22551 "$4,013.36 " 43239 "$1,463.70 " 73090 $320.16 22845 "$2,874.93 " 49505 "$4,621.61 " 73100 $274.15 23120 "$3,383.66 " 49520 "$4,871.66 " 73110 $370.05 23410 "$5,583.40 " 49560 "$3,603.48 " 73130 $347.09 23412 "$4,557.66 " 49568 "$2,539.40 " 73140 $273.36 23420 "$5,070.48 " 49585 "$3,775.18 " 73560 $273.91 23430 "$3,457.31 " 49587 "$3,700.72 " 73562 $284.58 23700 "$2,353.77 " 49650 "$5,479.30 " 73590 $340.75 24341 "$5,825.35 " 55520 "$3,593.28 " 73600 $275.83 24342 "$8,359.69 " 62264 "$1,119.98 " 73610 $379.58 25000 "$2,857.99 " 62282 $794.72 73620 $308.53 25607 "$6,580.21 " 62310 "$1,154.42 " 73630 $382.66 25608 "$5,825.46 " 62311 "$1,059.70 " 76000 $570.68 25609 "$7,380.11 " 62368 "$5,677.78 " 76001 $718.57 26055 "$2,142.83 " 63030 "$7,673.16 " 76937 $549.21 26418 "$2,498.81 " 63047 "$6,281.55 " 76942 $866.95 26615 "$5,505.61 " 63650 "$4,786.33 " 77001 $766.95 26735 "$5,180.91 " 63685 "$4,570.88 " 77002 $384.90 26765 "$3,312.20 " 64415 "$1,177.58 " 77003 $468.42 28485 "$5,613.85 " 64447 "$1,547.25 " 80047 $157.60 29515 $151.80 64450 $962.38 80048 $164.79 29581 $201.27 64470 "$1,501.52 " 80053 $203.32 29806 "$4,749.02 " 64475 "$1,617.29 " 81001 $89.48 Appendix C: Scheduled Outpatient Surgical Services Subject to modification based on county of service. See Appendix A. CPT Base Rate CPT Base Rate CPT Base Rate 81003 $66.46 85576 $131.43 87205 $68.69 81025 $93.03 85610 $79.52 87206 $71.55 82565 $43.87 85730 $102.49 87641 $124.40 82947 $26.63 86850 $75.92 88300 $102.90 82948 $17.69 86900 $43.98 88302 $159.18 82962 $19.25 86901 $41.35 88304 $229.92 84132 $49.82 87015 $47.91 88305 $304.79 84295 $42.22 87070 $176.71 88307 $393.80 84520 $42.01 87075 $183.67 88311 $119.38 84703 $123.25 87077 $90.91 99218 $96.88 85014 $38.67 87081 $63.79 99219 $219.53 85018 $34.48 87102 $145.16 99220 $67.48 85025 $122.09 87116 $162.38 85027 $82.81 87186 $101.75