CurrentFlorida BluePolicy N/A

CT scan reimbursement fee schedule entries

Lists CPT/HCPCS procedure codes for CT scans with modifier-specific allowed amounts (professional/facility/technical splits) applicable to Florida Blue reimbursement; affects providers submitting CT imaging claims.

Policy Summary

PayerFlorida Blue

PolicyCT scan reimbursement fee schedule entries

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionUse the listed modifier-specific allowed amounts when submitting CT imaging claims for Florida Blue reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~150code-modifier lines

$1,282.70largest allowed amount

$56.72example low professional amount

some $0.00zero-dollar entries

Coverage / Pricing Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Reimbursement amounts — CT imaging

Fee schedule entries indicating reimbursement amounts for CT procedures.

Allowed amounts are provided per procedure code and modifier; no clinical coverage or prior-authorization criteria are included in these lines.

ALL of the following

Examples of CT procedure lines
- Procedure code 0633T with modifier 02 — Allowed Amount $275.94.
- Procedure code 0634T with modifier 02 — Allowed Amount $275.94.
- Procedure code 0635T with modifier 02 — Allowed Amount $275.94.
- Procedure code 0636T with modifier 02 — Allowed Amount $275.94.
- Procedure code 0638T with modifier 02 — Allowed Amount $275.94.
ALL of the following
- Procedure code 70450 — modifier 02 Allowed Amount $151.41; modifier 26 Allowed Amount $56.72; modifier TC Allowed Amount $94.69.
- Procedure code 70460 — modifier 02 Allowed Amount $211.02.
- Procedure code 70470 — modifier 02 Allowed Amount $249.69; modifier 26 $84.48; modifier TC $165.22.
- Procedure code 70471 — modifier 02 Allowed Amount $481.69; modifier 26 $153.34; modifier TC $328.35.
ALL of the following
- Procedure code 70491 — modifier 02 Allowed Amount $306.26.

Document-level summary: multiple CT scan codes list distinct allowed amounts by modifier (02, 26, TC) and facility/professional splits; these are pricing entries only.

Per-code reimbursement rules (excerpt)

Reimbursement table entries — payer lists per-code amounts and component/modifier-specific prices.

ALL of the following

IDTC - GENERAL DIAGNOSTIC mapping examples include entries where input/base values map to per-code reimbursement amounts with component designators (02, 26, TC or blank).
Sample per-code mappings (excerpt)
- Code 70110 — component 02 mapping with resulting reimbursement shown (example $49.44).
- Code 70120 — component TC mapping with resulting reimbursement shown (example $31.94).
- Code 70330 — component 02 mapping with input $62.72 producing reimbursements such as $16.59, $46.14, $104.32 depending on component assignment.

Many lines show $0.00 as an input/base value and then list component-specific reimbursements; entries are pricing/mapping rows, not clinical criteria.

Example reimbursement mappings

Price mapping entries (examples):

ALL of the following

Code 73565 — component TC mapping with amount $46.78 (example derived reimbursement).
Code 73580 — component 02 mapping with amount $148.16 (example derived reimbursement).
Code 73592 — component 02 mapping with amount $36.24 (example derived reimbursement).
Code 74240 — component 02 mapping with amount $46.01 and component TC mapping with amount $100.64 (both present in excerpt).
Code 74400 — component 02 mapping with amount $143.30 and mapped to higher-level IDTC target 75580 with component TC producing $1,110.71 in one line.

These are illustrative mapping rows showing how a base/input value maps to component-specific reimbursement amounts; no medical necessity criteria are expressed.

Pricing-only excerpt

Fee schedule entries only; no coverage criteria expressed in these chunks.

This excerpt contains fee schedule/pricing mappings (IDTC - GENERAL DIAGNOSTIC) to CPT/HCPCS codes with TC/26/02 modifiers and dollar amounts; it does not include prior authorization, medical necessity, or documentation criteria.

Example: 74400 mapped to 75580 with TC = 02 producing $1,110.71 (pricing output shown).

Reimbursement mappings (partial)

Pricing and code mapping lines present in this excerpt (partial).

ALL of the following

Code 91124 appears with multiple component assignments (TC/26/02) and a set of derived amounts reported (examples include $767.28 and derived values $444.04, $183.69, $260.35).
HCPCS/Q-code block: Q4407 and related Q44xx mappings repeat with a consistent base/derived amount $161.14 across many target mappings.

Partial excerpt shows repeated base values and multiple component designators; entries are pricing/mapping rows, not clinical rules.

Payment line items only

This excerpt provides specific payment amounts and component designations for listed medicine procedure codes; it does not include clinical coverage criteria.

ALL of the following

Representative medicine mapping examples
- Q4407 mapped to 93005 — 02 component resulting in $22.49 (derived from $161.14 base).
- Q4407 mapped to 93024 — component 02 results shown (examples include $145.61 base-derived values; 26/TC splits also listed).
- 93050 mapped across multiple targets with TC/26/02 component rows and specific payment splits (examples provided in excerpt).

These are fee schedule mappings only; no medical necessity, prior auth, or documentation conditions are present.

Pricing-only segment; no coverage rules

No explicit coverage criteria or medical necessity rules are present in this excerpt; only pricing/mapping data.

IDTC - MEDICINE lines map source procedure codes (e.g., 94450, 95707, 95919 family) to target CPT/HCPCS codes with component designations (02, 26, TC) and computed payment amounts; some computed outputs equal $0.00 for certain mappings.

Examples include 95707 source charge $650.00 mapped producing derived payments (e.g., $187.50, $180.50) and 95962-derived rows with some resulting $0.00 outputs.

Reimbursement rate table (excerpt)

Reimbursement entries (mapping rows):

IDTC mapping rows in this segment show multiple medicine and MRI/MRA related target codes with component indicators and computed reimbursements (examples: 95962-derived rows with computed amounts; MRI/MRA Q4403 mappings showing multiple component-derived values).

Entries include combined input pairs (e.g., $231.61.$113.92 pattern) used to compute per-target reimbursements; some lines produce $0.00 outputs.

Reimbursement table excerpt

This excerpt lists reimbursement amounts and component designations for MRI/MRA codes; it does not include clinical coverage criteria.

ALL of the following

MRI/MRA mapping examples
- Q4403 mapped to 70546 with component 02 producing derived amounts such as $424.34, $775.88, $656.56 depending on component assignment.
- 70547 entries show component-driven derived values across 02/26/TC assignments with examples ranging from $119.31 to $780.45 and higher.
- 75561 mapping rows include component-specific derived reimbursements (examples: $383.11, $656.78, $192.59, $464.19) and lower target-derived amounts (e.g., $13.62).

These lines are pricing/mapping data only; they do not impose medical necessity or prior authorization criteria.

CPT / HCPCS Code Mappings and Rates

sample CT codes and allowed amountsCPTCovered

0633T	CT scan (specific IDTC procedure code) — modifier 02 allowed amount $275.94
0634T	CT scan — modifier 02 allowed amount $275.94
0635T	CT scan — modifier 02 allowed amount $275.94
0636T	CT scan — modifier 02 allowed amount $275.94
0638T	CT scan — modifier 02 allowed amount $275.94
70450	CT scan, head/brain — modifier 02 allowed amount $151.41; modifier 26 allowed amount $56.72; modifier TC allowed amount $94.69
70460	CT scan — modifier 02 allowed amount $211.02; modifier 26 $74.66; modifier TC $136.36
70470	CT scan — modifier 02 allowed amount $249.69; modifier 26 $84.48; modifier TC $165.22
70471	CT scan — modifier 02 allowed amount $481.69; modifier 26 $153.34; modifier TC $328.35

CT scan mappingsCPT

74160	CT abdomen/pelvis (example mapping to other internal code 74262 shown)
74262	Mapped/internal representation shown in table

Digital mammography codesmixed

77061	Digital mammography
77062	Digital mammography
G0279	Diagnostic mammography HCPCS

General diagnostic (temporary) codesCPT

0358T	General diagnostic (temporary CPT)
0554T	General diagnostic (temporary CPT)

Sample CPT/HCPCS codes appearing in excerptCPTCovered

70110	Diagnostic imaging code shown as mapped from IDTC entries
70330	Diagnostic imaging code with multiple modifier/component price lines
71111	Diagnostic imaging code with component-specific reimbursements

Extracted example mappings from IDTC - GENERAL DIAGNOSTICmixed

71111	Mapped/paired with 72083 or 72084 and various TC indicators and dollar amounts
72110	Repeated mapping base; mapped to multiple codes (72114, 72120, 72170, 72190, 72200, etc.) with TC indicators and amounts
73020	Mapped to 73020/73030/73040/etc. with TC indicators and amounts
73140	Mapped to 73501/73502/73503/73521/etc. with TC indicators and amounts

sample CPT/HCPCS codes in excerptCPT

73565	Referenced mapping for IDTC - GENERAL DIAGNOSTIC
73580	Referenced mapping for IDTC - GENERAL DIAGNOSTIC
73590	Referenced mapping for IDTC - GENERAL DIAGNOSTIC
73592	Referenced mapping for IDTC - GENERAL DIAGNOSTIC
73600	Referenced mapping for IDTC - GENERAL DIAGNOSTIC
74240	Referenced mapping for IDTC - GENERAL DIAGNOSTIC
74328	Referenced mapping for IDTC - GENERAL DIAGNOSTIC
74400	Referenced mapping for IDTC - GENERAL DIAGNOSTIC
75580	Referenced mapping for IDTC - GENERAL DIAGNOSTIC

Diagnostic radiology code fee mappings (partial)CPT | HCPCS

75801-75898 (various)

Multiple angiography/diagnostic radiology codes listed with alternate TC/02/26 designations and corresponding fees

Additional diagnostic code fee mappings (partial)CPT | HCPCS

74400, 74740-74775, 75580, 75600-75774 (various)

Listed in association with IDTC - GENERAL DIAGNOSTIC entries and fee values

Observed CPT/HCPCS mappings in pricing tablemixed

75880	Referenced and mapped to multiple codes such as 76019, 76080, 76098, 76100 in pricing lines
76100	Mapped to ranges including 76120, 76497, 76499, 76506, 76510, etc., with associated prices
76641	Mapped to numerous ultrasound/diagnostic codes (e.g., 76700, 76801, 76811, etc.) with listed prices
76814	Mapped to a series of codes 76815–76831, 76856–76857 with listed prices

Sample CPT/HCPCS codes listed (partial)mixed

76814	Ultrasound (example mapping present in table)
76830	Ultrasound — CPT pairing shown
77003	Radiology code shown in table

sample mappings in this excerptmixed

Q4407	Mapped to multiple Q44xx and Q44xx->various CPT/HCPCS; base $161.14 shown
91124	Mapped to many diagnostic services with base $767.28 in several lines
77053	Mammography mapping with split 02/26/TC and dollar splits shown

Examples of CPT crosswalks and paymentsCPT

93050	Listed with multiple associated procedure codes (e.g., 93145–93319) and payment splits
93303	Appears with TC/02/26 component rows and specific payment amounts

mapped procedure codes (examples)CPT | HCPCS

94450

Listed as source code mapped to multiple procedure codes (examples in this chunk: 94640, 94642, 94660, 94664, 94667, 94668, 94680, 94681, 94690, 94726, 94727, 94728, 94729, 94760, 94761, 94762, 94772, 95700, 95705, 95706, etc.)

95707 mappings and computed paymentsCPT | HCPCS

95707

Source charge example ($650.00) mapped to a range of other codes (95708-959xx) with computed payment amounts listed.

95919 family mappingsCPT | HCPCS

95919

Source charge example ($7.54) mapped across multiple target codes (95921-95962 and beyond) with TC/02/26 modifiers and computed amounts.

MRI/MRA CPT mappingsCPTCovered

70336	CT/MRI related CPT listed with multiple component rates
70540	MRI CPT with component and total rates
70542	MRI CPT with component and total rates
70543	MRI CPT with component and total rates
70544	MRI CPT with component and total rates
70545	MRI CPT with component and total rates
70546	MRI CPT with component and total rates
70547	MRI CPT with component and total rates

HCPCS G-codesHCPCSCovered

G0537	G-series HCPCS listed with component rates
G0540	G-series HCPCS listed with component rates
G0551	G-series HCPCS listed with component rates

MRI/MRA CPT/HCPCS mappingsCPT

70546	MRI/MRA code mapped from Q4403 in table lines
70547	MRI/MRA code appearing repeatedly with multiple charge types and amounts
72149	MRI/MRA code present with multiple TC/02/26 designations and dollar amounts

MRI/MRA mappings (sample)CPT

75561	MRI/MRA code referenced as source mapping
76014	Target code mapped from 75561 in excerpt
76015	Target code mapped from 75561 in excerpt

Nuclear Medicine mappings (sample)CPT

77084	Referenced base code linked to Nuclear Medicine target codes
78012	Nuclear Medicine target code
78013	Nuclear Medicine target code

Representative CPT mappingsCPT

78103	Mapped/paired to other CPTs (e.g., 78202) in IDTC table
78202	Appears repeatedly as target mapping
78300	Numerous mappings with TC variants and prices

Examples of facility vs professional splits

Example line with facility/global split (Modifier 02)70450 modifier 02 allowed amount $151.41 (facility/global component shown separately from 26/TC)

Example professional component (Modifier 26)70450 modifier 26 allowed amount $56.72 (professional component)

Example technical component (Modifier TC)70450 modifier TC allowed amount $94.69 (technical component)

Repeated Modifier 02 across CT procedure codesSeveral CT procedure codes (0633T–0638T) list modifier 02 allowed amount $275.94 (facility/global)

Minimum listed reimbursement (excerpt)

Minimum listed reimbursement in excerpt$11.16

Context exampleShown as derived payment for medicine mapping (93970 -> 94010, modifier 26) yielding $11.16

Document range noteThis value is within multiple TC/26/02 split lines in the excerpt

Maximum listed reimbursement (excerpt)

Maximum listed reimbursement in excerpt$121.55

Context exampleAppears as a derived amount for 70330 = 70390 with component 02 = 02 yielding $121.55

Document range noteThis is one of the explicit per-line reimbursement values shown in the diagnostic mapping excerpt

Maximum amount in excerpt

Max amount observed in chunk$1,110.71

Source lineIDTC - GENERAL DIAGNOSTIC, 74400 = 75580, TC = 02 yields $1,110.71

ContextDisplayed as the computed reimbursement for mapping to 75580 in the excerpt

Minimum amount in excerpt

Minimum amount observed in chunk$8.91

Source lineIDTC - GENERAL DIAGNOSTIC, 73592 = 73660, 26 = 26 yields $8.91

ContextOne of the smallest per-line derived reimbursement values in the diagnostic mapping excerpt

Displayed maximum example reimbursement

Displayed maximum example reimbursement$978.82

Source lineIDTC - GENERAL DIAGNOSTIC, 77003 = 91124, 02 = 02 yields $978.82

ContextShown as a displayed derived reimbursement for 91124 mapping in the excerpt

Displayed minimum example reimbursement

Displayed minimum example reimbursement$0.00

Source lineIDTC - GENERAL DIAGNOSTIC entries (e.g., 76946 mappings) include $0.00 as derived reimbursement for some component rows

ContextMultiple lines show $0.00 as the derived amount in this segment

Zero-dollar entries

Zero-dollar entries (examples)Codes 96379, 97037 and other mappings show $0.00 derived reimbursement in this excerpt

Source linesIDTC - GENERAL DIAGNOSTIC, 91124 = 96379 -> $0.00; 91124 = 97037 -> $0.00; G0137 mappings show $0.00 = $161.14 input translating to outputs

Document noteSome mapping inputs or component rows are zero-dollar in this table segment

Example repeated payment amount

Repeated payment amount example$210.90 appears as a base/payment value used across multiple medicine mappings

Source linesIDTC - MEDICINE entries (e.g., 93970 mappings) repeatedly use $210.90 as the input/base amount producing various derived reimbursements

Operational note$210.90 is reused as a base/payment value across many mapping rows in the medicine section

Example zero payment mapping

Example zero payment mappingIDTC - MEDICINE mapping 95962.95962 = 97037 yields $0.00 derived reimbursement

Source lineIDTC - MEDICINE, 95962.95962 = 97037, 26.TC = 02, $231.61.$113.92 = $0.00

ContextSome computed mappings in the medicine section result in $0.00 payments in this excerpt

Billing, Coding, and Provider Notices

Billing Rule

Billing and reimbursement mapping — provider billing rules

This excerpt is a fee-schedule style mapping of procedure codes to allowed amounts and billing component (professional/technical/other) splits. It contains CT scan price/mapping lines, rate-table provider billing entries, and multiple mapped pricing groups for diagnostic imaging and medicine. No prior authorization, step-therapy, or denial actions are specified in the excerpt; these are pricing/reimbursement mappings only. Providers should bill using the listed CPT/HCPCS codes and indicated modifier/component (02, 26, TC, or blank) and expect payment per the allowed amounts shown.

CT scan pricing/mapping lines list individual procedure codes (e.g., 0633T–0638T, 70450, 70460) with allowed amounts and component/modifier indicators (02, 26, TC).
Rate table / provider billing entries include dollar values for TC/26/02 splits across many CT and diagnostic codes (examples: 74160 mapped to 74262 with TC/02/26/TC splits and dollar values).
Digital mammography entries (77061–77067 and G0279) mapped with component splits and allowed amounts are included.
General diagnostic code price entries and numerous IDTC - GENERAL DIAGNOSTIC mappings to CPT/HCPCS codes are present with TC/26/02 indicators and allowed dollar amounts.
Medicine pricing/mapping entries (IDTC - MEDICINE) map codes such as Q4407 and 94450 to various CPT codes with component indicators and allowed amounts.
Reimbursement mapping excerpt consolidates IDTC groups (CT SCAN, GENERAL DIAGNOSTIC, MEDICINE, MRI/MRA, NUCLEAR MEDICINE) to CPT/HCPCS codes with specified allowed amounts and billing component designations.

Terms and Charge Component Definitions

Modifier meanings

Modifier 26Professional component (modifier 26) — shown as separate component rows with distinct allowed amounts (e.g., 70450 modifier 26 = $56.72)

Modifier TCTechnical component (TC) — shown with separate allowed amounts (e.g., 70450 modifier TC = $94.69)

Modifier 02Modifier 02 used in this table to indicate a facility/global or other payer-defined split component (examples: many CT and IDTC entries list modifier 02 amounts such as $275.94 for 0633T or 02 component rows across mappings)

Usage noteEntries frequently show TC/26/02 alongside code mappings to indicate which component (technical/professional/facility or global split) the listed amount applies to

TC / modifier indicators

TC / 26 / 02 indicatorsTable rows include TC, 26 and 02 component indicators to denote technical, professional or facility/global split designations for pricing

ExampleIDTC - GENERAL DIAGNOSTIC rows show entries such as 0865T = 70110 with 02/26/TC and derived dollar amounts

Operational impactProviders should bill with the appropriate modifier to match the component-specific allowed amount recorded in the fee table

General diagnostic / temporary CPT examples

Temporary / diagnostic CPT examplesCodes such as 0358T, 0485T, 0554T appear as temporary CPT or specific diagnostic procedure codes with listed dollar mappings in the table

Source exampleIDTC - GENERAL DIAGNOSTIC, 77063 = 0358T and 0485T with associated derived amounts

NoteThese temporary CPT entries are included in the fee mapping excerpt with component indicators and dollar values

IDTC - GENERAL DIAGNOSTIC

IDTC labelIDTC - GENERAL DIAGNOSTIC is used as the descriptor for this block of diagnostic imaging price/code mappings

UsageRows labeled IDTC - GENERAL DIAGNOSTIC map internal/base codes to CPT/HCPCS target codes with component indicators and derived amounts

Example mappingIDTC - GENERAL DIAGNOSTIC, 71111 mappings to 72083/72084 with TC/02/26 rows and dollar values

Modifier / component indicators

Component indicators usedTC, 02 and 26 indicate claim component or modifier designations (technical component, facility/global split, professional component) in the pricing lines

Display formatComponent indicators appear alongside mapping lines (e.g., 'TC = 02' or 'TC = 26') to show which component the dollar amount corresponds to

Provider actionEnsure billed modifiers align with the component row used to derive reimbursement

TC indicator values

TC indicator valuesValues displayed include '02', '26', 'TC' or blank to mark technical/professional/facility or unspecified components

Example entriesRows such as 76814 mappings show 02/26/TC variants with distinct derived amounts (e.g., $108.62 = $160.39 for 02)

InterpretationBlank component fields occasionally appear; explicit TC/26/02 flags indicate which component's allowed amount is listed

IDTC - GENERAL DIAGNOSTIC descriptor

IDTC - GENERAL DIAGNOSTIC descriptorUsed as the internal descriptor for the diagnostic imaging pricing dataset block (maps internal base to target CPT/HCPCS codes)

ExampleLines under this label include mappings such as 73140 -> 73565 with TC/26/02 component rows and dollar amounts

ScopeApplies to multiple diagnostic imaging code mappings in the excerpt

TC / 26 / 02 notation meaning

TC / 26 / 02 notation meaningDenotes payment component: TC = technical component; 26 = professional component; 02 = facility/global or other split — used to classify which component the listed amount applies to

AppearanceNotations appear on nearly every mapping line to show component-specific derived reimbursements

Billing implicationCorrect modifier selection on claims will determine which component-specific allowed amount applies

Charge component indicators (TC/26/02)

Common component indicatorsTC / 26 / 02 are used throughout the fee entries to indicate technical component, professional component (modifier 26), and facility/global split (02)

Example usageMany IDTC mappings list the same CPT target with separate TC, 26 and 02 rows showing distinct dollar outputs

Provider noteMatch submitted claim modifiers to the appropriate component row to receive the corresponding allowed amount

Modifiers indicating Technical / Professional components

Modifiers indicating TC or 26 and other designationsEntries explicitly use 'TC' or '26' (and '02') to indicate technical or professional billing components in the fee table

ExamplesRows such as 76814 and 73140 show TC/26/02 variants with distinct derived amounts

Operational impactThese modifier indicators determine which component-specific reimbursement to apply when adjudicating claims

Component indicator display

Component designators displayed'02', '26' and 'TC' are displayed as component designators associated with listed entries to indicate facility/global, professional, or technical components

Example linesIDTC mapping rows show patterns like 'TC = 02' or 'TC = 26' next to monetary mappings

Provider guidanceUse the table's component designator to reconcile billed modifiers with allowed amounts

Pricing mapping format

Pricing mapping formatEntries are presented as 'IDTC - [SECTION], [base] = [target code]' with an associated dollar mapping (input = derived amount) to indicate pricing transformation

Example'IDTC - GENERAL DIAGNOSTIC, $110.71 = $72.24' (74400 = 74740) shows input base and derived reimbursement

ImplicationThis format is used across the excerpt to show how base values map to target CPT/HCPCS reimbursements by component

G0137 / Q-code mapping block

G0137 / Q-code blockG0137 is mapped repeatedly to numerous Q4xxx codes with a consistent derived value of $161.14 in this excerpt

Source linesIDTC - GENERAL DIAGNOSTIC, G0137 mappings show $0.00 = $161.14 as input producing $161.14 outputs for many Q-codes

Operational noteA recurring $161.14 base/derived amount is used across the G0137/Q-code block

Service component indicators

Service component indicators overviewThe table denotes service components as TC (technical), 26 (professional) and 02 (facility/global split) across pricing lines

ExampleEntries for 71111, 76814 and similar codes show separate amounts for TC/26/02 rows

Provider actionBill with the component-specific modifier to align with the listed allowed amount

Modifier types used

Modifier types used in entriesModifier indicators seen include TC (technical component), 26 (professional) and 02 (facility/global or payer split)

Example rowsIDTC lines show variants for each modifier type with distinct derived amounts (e.g., 76814 rows for 02/26/TC)

Billing implicationModifiers determine which component-specific reimbursement is applicable

IDTC - MEDICINE identifier

IDTC - MEDICINE prefix'IDTC - MEDICINE' is used as an internal identifier prefix for the medicine section of the pricing dataset

ExampleRows under IDTC - MEDICINE map codes like 93005–93050, Q4407 and others to derived dollar amounts with component indicators

ScopeApplied across the medicine-related fee mappings in the excerpt

TC / 26 / 02 shorthand

Charge component shorthand (TC/26/02)Used throughout the table to indicate technical component (TC), professional component (26) and facility/global split (02)

Example appearanceLines frequently include 'TC = 02' or 'TC = 26' adjacent to monetary mappings

Interpretive noteThese shorthand indicators are applied consistently across service categories in the excerpt

IDTC (internal derived mapping)

IDTC as internal derived mappingIDTC is used to map source CPT codes to alternate CPT/HCPCS codes and to derive dollar amounts used for reimbursement logic

ExamplesIDTC blocks include MEDICINE, GENERAL DIAGNOSTIC, MRI/MRA and NUCLEAR MEDICINE mappings with component-based derived amounts

Operational useThese IDTC mappings feed payer calculations to generate the shown allowed amounts by component

Modifier designations in mappings

Modifier designations in mappingsMappings include explicit designations indicating technical component (TC) or modifier 26/02 assignment for professional/technical billing splits

Source evidenceMultiple IDTC - MEDICINE and IDTC - MRI/MRA rows show 'TC', '26' or '02' next to derived dollar values

Billing implicationUse these designations to determine which allowed amount applies when adjudicating claims

TC technical component indicator

TC technical component indicator'TC' is used in the table to denote the technical component billing line and associated allowed amounts

ExamplesSeen across GENERAL DIAGNOSTIC, MEDICINE and MRI/MRA IDTC blocks as 'TC' rows producing component-specific derived amounts

Provider guidanceEnsure TC billing aligns with the TC row to receive the technical-component allowed amount

IDTC - NUCLEAR MEDICINE descriptor

IDTC - NUCLEAR MEDICINE descriptorInternal descriptor 'IDTC - NUCLEAR MEDICINE' used for nuclear medicine pricing/pricing lines

ExampleRows map 77084 to nuclear medicine CPT targets (e.g., 76977, 77338) with component-specific derived amounts

ContextApplied to the nuclear medicine section of the fee mapping excerpt

Policy Summary

PayerFlorida Blue

PolicyCT scan reimbursement fee schedule entries

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionUse the listed modifier-specific allowed amounts when submitting CT imaging claims for Florida Blue reimbursement.

SourceLink

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