hospital_name	last_updated_on	version	hospital_location	hospital_address	license_number|ID	"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated."											
Bear Lake County Memorial Hospital	7/10/2024	2.0.0	Bear Lake Memorial Hospital	"164 S 5th Street, Montpelier, ID, 83254"	35	TRUE											
description	code|1	code|1|type	code|2	code|2|type	modifiers	setting	standard_charge|gross	standard_charge|discounted_cash	payer_name	plan_name	standard_charge|methodology	standard_charge|negotiated_dollar	standard_charge|negotiated_percentage	standard_charge|negotiated_algorithm	additional_generic_notes	standard_charge|min	standard_charge|max
SEMI-PRIVATE 1	100	RC				inpatient	1248	1060.8	Blue Cross of ID	Default	Percent of Total Billed Charges	1198.08				723.84	3495
SEMI-PRIVATE 1	100	RC				inpatient	1248	1060.8	Medicaid Idaho	Default	Percent of Total Billed Charges	723.84				723.84	3495
SEMI-PRIVATE 1	100	RC				inpatient	1248	1060.8	Medicare A ID JF	Default	Per Diem	3495				723.84	3495
SEMI-PRIVATE 1	100	RC				inpatient	1248	1060.8	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		723.84	3495
SEMI-PRIVATE 1	100	RC				inpatient	1248	1060.8	Regence Group Administrators	Default	Percent of Total Billed Charges	1210.56				723.84	3495
SEMI-PRIVATE 1	100	RC				inpatient	1248	1060.8	SelectHealth	Default	Percent of Total Billed Charges	1185.6				723.84	3495
"TPN SOLUTION, 74-100 G PROTEIN/ UNIT"	B4197	HCPCS	272	RC		both	361	306.85	Blue Cross of ID	Default	Percent of Total Billed Charges	350.17				140.79	350.17
"TPN SOLUTION, 74-100 G PROTEIN/ UNIT"	B4197	HCPCS	272	RC		both	361	306.85	Medicaid Idaho	Default	Fee Schedule	166.06				140.79	350.17
"TPN SOLUTION, 74-100 G PROTEIN/ UNIT"	B4197	HCPCS	272	RC		both	361	306.85	Medicare A ID JF	Default	Other	140.79		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	140.79	350.17
"TPN SOLUTION, 74-100 G PROTEIN/ UNIT"	B4197	HCPCS	272	RC		both	361	306.85	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		140.79	350.17
"TPN SOLUTION, 74-100 G PROTEIN/ UNIT"	B4197	HCPCS	272	RC		both	361	306.85	Regence Group Administrators	Default	Fee Schedule	350.17				140.79	350.17
"TPN SOLUTION, 74-100 G PROTEIN/ UNIT"	B4197	HCPCS	272	RC		both	361	306.85	SelectHealth	Default	Percent of Total Billed Charges	342.95				140.79	350.17
IV FILTR PER UNIT	B9999	HCPCS	272	RC		both	14	11.9	Blue Cross of ID	Default	Percent of Total Billed Charges	13.58				5.46	13.58
IV FILTR PER UNIT	B9999	HCPCS	272	RC		both	14	11.9	Medicaid Idaho	Default	Fee Schedule	6.44				5.46	13.58
IV FILTR PER UNIT	B9999	HCPCS	272	RC		both	14	11.9	Medicare A ID JF	Default	Other	5.46		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	5.46	13.58
IV FILTR PER UNIT	B9999	HCPCS	272	RC		both	14	11.9	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		5.46	13.58
IV FILTR PER UNIT	B9999	HCPCS	272	RC		both	14	11.9	Regence Group Administrators	Default	Fee Schedule	13.58				5.46	13.58
IV FILTR PER UNIT	B9999	HCPCS	272	RC		both	14	11.9	SelectHealth	Default	Percent of Total Billed Charges	13.3				5.46	13.58
SWING BED-MEDICARE	100	RC				inpatient	948	805.8	Blue Cross of ID	Default	Percent of Total Billed Charges	910.08				549.84	3495
SWING BED-MEDICARE	100	RC				inpatient	948	805.8	Medicaid Idaho	Default	Percent of Total Billed Charges	549.84				549.84	3495
SWING BED-MEDICARE	100	RC				inpatient	948	805.8	Medicare A ID JF	Default	Per Diem	3495				549.84	3495
SWING BED-MEDICARE	100	RC				inpatient	948	805.8	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		549.84	3495
SWING BED-MEDICARE	100	RC				inpatient	948	805.8	Regence Group Administrators	Default	Percent of Total Billed Charges	919.56				549.84	3495
SWING BED-MEDICARE	100	RC				inpatient	948	805.8	SelectHealth	Default	Percent of Total Billed Charges	900.6				549.84	3495
RECOVERY ROOM LEVEL 3 PER 15MIN	710	RC				both	108.5	92.23	Blue Cross of ID	Default	Percent of Total Billed Charges	105.24				42.32	105.24
RECOVERY ROOM LEVEL 3 PER 15MIN	710	RC				both	108.5	92.23	Medicaid Idaho	Default	Fee Schedule	49.91				42.32	105.24
RECOVERY ROOM LEVEL 3 PER 15MIN	710	RC				both	108.5	92.23	Medicare A ID JF	Default	Other	42.32		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	42.32	105.24
RECOVERY ROOM LEVEL 3 PER 15MIN	710	RC				both	108.5	92.23	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		42.32	105.24
RECOVERY ROOM LEVEL 3 PER 15MIN	710	RC				both	108.5	92.23	Regence Group Administrators	Default	Fee Schedule	105.24				42.32	105.24
RECOVERY ROOM LEVEL 3 PER 15MIN	710	RC				both	108.5	92.23	SelectHealth	Default	Percent of Total Billed Charges	103.08				42.32	105.24
RECOVERY ROOM LEVEL 2 PER 15 MINUTE	710	RC				both	59	50.15	Blue Cross of ID	Default	Percent of Total Billed Charges	57.23				23.01	57.23
RECOVERY ROOM LEVEL 2 PER 15 MINUTE	710	RC				both	59	50.15	Medicaid Idaho	Default	Fee Schedule	27.14				23.01	57.23
RECOVERY ROOM LEVEL 2 PER 15 MINUTE	710	RC				both	59	50.15	Medicare A ID JF	Default	Other	23.01		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	23.01	57.23
RECOVERY ROOM LEVEL 2 PER 15 MINUTE	710	RC				both	59	50.15	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		23.01	57.23
RECOVERY ROOM LEVEL 2 PER 15 MINUTE	710	RC				both	59	50.15	Regence Group Administrators	Default	Fee Schedule	57.23				23.01	57.23
RECOVERY ROOM LEVEL 2 PER 15 MINUTE	710	RC				both	59	50.15	SelectHealth	Default	Percent of Total Billed Charges	56.05				23.01	57.23
RECOVERY ROOM LEVEL 1 PER 15 MINUTE	710	RC				both	32	27.2	Blue Cross of ID	Default	Percent of Total Billed Charges	31.04				12.48	31.04
RECOVERY ROOM LEVEL 1 PER 15 MINUTE	710	RC				both	32	27.2	Medicaid Idaho	Default	Fee Schedule	14.72				12.48	31.04
RECOVERY ROOM LEVEL 1 PER 15 MINUTE	710	RC				both	32	27.2	Medicare A ID JF	Default	Other	12.48		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	12.48	31.04
RECOVERY ROOM LEVEL 1 PER 15 MINUTE	710	RC				both	32	27.2	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		12.48	31.04
RECOVERY ROOM LEVEL 1 PER 15 MINUTE	710	RC				both	32	27.2	Regence Group Administrators	Default	Fee Schedule	31.04				12.48	31.04
RECOVERY ROOM LEVEL 1 PER 15 MINUTE	710	RC				both	32	27.2	SelectHealth	Default	Percent of Total Billed Charges	30.4				12.48	31.04
RECOVERY ROOM DENTAL	710	RC				both	155	131.75	Blue Cross of ID	Default	Percent of Total Billed Charges	150.35				60.45	150.35
RECOVERY ROOM DENTAL	710	RC				both	155	131.75	Medicaid Idaho	Default	Fee Schedule	71.3				60.45	150.35
RECOVERY ROOM DENTAL	710	RC				both	155	131.75	Medicare A ID JF	Default	Other	60.45		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	60.45	150.35
RECOVERY ROOM DENTAL	710	RC				both	155	131.75	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		60.45	150.35
RECOVERY ROOM DENTAL	710	RC				both	155	131.75	Regence Group Administrators	Default	Fee Schedule	150.35				60.45	150.35
RECOVERY ROOM DENTAL	710	RC				both	155	131.75	SelectHealth	Default	Percent of Total Billed Charges	147.25				60.45	150.35
RECOVERY VITAL SYSTEMS MONITORING	710	RC				both	419.5	356.58	Blue Cross of ID	Default	Percent of Total Billed Charges	406.92				163.61	406.92
RECOVERY VITAL SYSTEMS MONITORING	710	RC				both	419.5	356.58	Medicaid Idaho	Default	Fee Schedule	192.97				163.61	406.92
RECOVERY VITAL SYSTEMS MONITORING	710	RC				both	419.5	356.58	Medicare A ID JF	Default	Other	163.61		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	163.61	406.92
RECOVERY VITAL SYSTEMS MONITORING	710	RC				both	419.5	356.58	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		163.61	406.92
RECOVERY VITAL SYSTEMS MONITORING	710	RC				both	419.5	356.58	Regence Group Administrators	Default	Fee Schedule	406.92				163.61	406.92
RECOVERY VITAL SYSTEMS MONITORING	710	RC				both	419.5	356.58	SelectHealth	Default	Percent of Total Billed Charges	398.52				163.61	406.92
SWING BED-MEDICAID	100	RC				inpatient	948	805.8	Blue Cross of ID	Default	Percent of Total Billed Charges	910.08				549.84	3495
SWING BED-MEDICAID	100	RC				inpatient	948	805.8	Medicaid Idaho	Default	Percent of Total Billed Charges	549.84				549.84	3495
SWING BED-MEDICAID	100	RC				inpatient	948	805.8	Medicare A ID JF	Default	Per Diem	3495				549.84	3495
SWING BED-MEDICAID	100	RC				inpatient	948	805.8	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		549.84	3495
SWING BED-MEDICAID	100	RC				inpatient	948	805.8	Regence Group Administrators	Default	Percent of Total Billed Charges	919.56				549.84	3495
SWING BED-MEDICAID	100	RC				inpatient	948	805.8	SelectHealth	Default	Percent of Total Billed Charges	900.6				549.84	3495
SWING BED-COMMERICAL	100	RC				inpatient	948	805.8	Blue Cross of ID	Default	Percent of Total Billed Charges	910.08				549.84	3495
SWING BED-COMMERICAL	100	RC				inpatient	948	805.8	Medicaid Idaho	Default	Percent of Total Billed Charges	549.84				549.84	3495
SWING BED-COMMERICAL	100	RC				inpatient	948	805.8	Medicare A ID JF	Default	Per Diem	3495				549.84	3495
SWING BED-COMMERICAL	100	RC				inpatient	948	805.8	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		549.84	3495
SWING BED-COMMERICAL	100	RC				inpatient	948	805.8	Regence Group Administrators	Default	Percent of Total Billed Charges	919.56				549.84	3495
SWING BED-COMMERICAL	100	RC				inpatient	948	805.8	SelectHealth	Default	Percent of Total Billed Charges	900.6				549.84	3495
SWING BED-ISOLATION	100	RC				inpatient	1646	1399.1	Blue Cross of ID	Default	Percent of Total Billed Charges	1580.16				954.68	3495
SWING BED-ISOLATION	100	RC				inpatient	1646	1399.1	Medicaid Idaho	Default	Percent of Total Billed Charges	954.68				954.68	3495
SWING BED-ISOLATION	100	RC				inpatient	1646	1399.1	Medicare A ID JF	Default	Per Diem	3495				954.68	3495
SWING BED-ISOLATION	100	RC				inpatient	1646	1399.1	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		954.68	3495
SWING BED-ISOLATION	100	RC				inpatient	1646	1399.1	Regence Group Administrators	Default	Percent of Total Billed Charges	1596.62				954.68	3495
SWING BED-ISOLATION	100	RC				inpatient	1646	1399.1	SelectHealth	Default	Percent of Total Billed Charges	1563.7				954.68	3495
SWING BED PRIVATE	100	RC				inpatient	461	391.85	Blue Cross of ID	Default	Percent of Total Billed Charges	442.56				267.38	3495
SWING BED PRIVATE	100	RC				inpatient	461	391.85	Medicaid Idaho	Default	Percent of Total Billed Charges	267.38				267.38	3495
SWING BED PRIVATE	100	RC				inpatient	461	391.85	Medicare A ID JF	Default	Per Diem	3495				267.38	3495
SWING BED PRIVATE	100	RC				inpatient	461	391.85	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		267.38	3495
SWING BED PRIVATE	100	RC				inpatient	461	391.85	Regence Group Administrators	Default	Percent of Total Billed Charges	447.17				267.38	3495
SWING BED PRIVATE	100	RC				inpatient	461	391.85	SelectHealth	Default	Percent of Total Billed Charges	437.95				267.38	3495
OXYGEN TENT HOURLY	410	RC				both	28	23.8	Blue Cross of ID	Default	Percent of Total Billed Charges	27.16				10.92	27.16
OXYGEN TENT HOURLY	410	RC				both	28	23.8	Medicaid Idaho	Default	Fee Schedule	12.88				10.92	27.16
OXYGEN TENT HOURLY	410	RC				both	28	23.8	Medicare A ID JF	Default	Other	10.92		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	10.92	27.16
OXYGEN TENT HOURLY	410	RC				both	28	23.8	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		10.92	27.16
OXYGEN TENT HOURLY	410	RC				both	28	23.8	Regence Group Administrators	Default	Fee Schedule	27.16				10.92	27.16
OXYGEN TENT HOURLY	410	RC				both	28	23.8	SelectHealth	Default	Percent of Total Billed Charges	26.6				10.92	27.16
OXYGEN HOURLY	270	RC				both	32	27.2	Blue Cross of ID	Default	Percent of Total Billed Charges	31.04				12.48	31.04
OXYGEN HOURLY	270	RC				both	32	27.2	Medicaid Idaho	Default	Fee Schedule	14.72				12.48	31.04
OXYGEN HOURLY	270	RC				both	32	27.2	Medicare A ID JF	Default	Other	12.48		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	12.48	31.04
OXYGEN HOURLY	270	RC				both	32	27.2	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		12.48	31.04
OXYGEN HOURLY	270	RC				both	32	27.2	Regence Group Administrators	Default	Fee Schedule	31.04				12.48	31.04
OXYGEN HOURLY	270	RC				both	32	27.2	SelectHealth	Default	Percent of Total Billed Charges	30.4				12.48	31.04
INCUBATOR OXYGEN HOURLY	410	RC				both	60.5	51.43	Blue Cross of ID	Default	Percent of Total Billed Charges	58.68				23.6	58.68
INCUBATOR OXYGEN HOURLY	410	RC				both	60.5	51.43	Medicaid Idaho	Default	Fee Schedule	27.83				23.6	58.68
INCUBATOR OXYGEN HOURLY	410	RC				both	60.5	51.43	Medicare A ID JF	Default	Other	23.6		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	23.6	58.68
INCUBATOR OXYGEN HOURLY	410	RC				both	60.5	51.43	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		23.6	58.68
INCUBATOR OXYGEN HOURLY	410	RC				both	60.5	51.43	Regence Group Administrators	Default	Fee Schedule	58.68				23.6	58.68
INCUBATOR OXYGEN HOURLY	410	RC				both	60.5	51.43	SelectHealth	Default	Percent of Total Billed Charges	57.48				23.6	58.68
INCENT SPIROMETRY TEACH/TREATMENT	270	RC				both	59	50.15	Blue Cross of ID	Default	Percent of Total Billed Charges	57.23				23.01	57.23
INCENT SPIROMETRY TEACH/TREATMENT	270	RC				both	59	50.15	Medicaid Idaho	Default	Fee Schedule	27.14				23.01	57.23
INCENT SPIROMETRY TEACH/TREATMENT	270	RC				both	59	50.15	Medicare A ID JF	Default	Other	23.01		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	23.01	57.23
INCENT SPIROMETRY TEACH/TREATMENT	270	RC				both	59	50.15	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		23.01	57.23
INCENT SPIROMETRY TEACH/TREATMENT	270	RC				both	59	50.15	Regence Group Administrators	Default	Fee Schedule	57.23				23.01	57.23
INCENT SPIROMETRY TEACH/TREATMENT	270	RC				both	59	50.15	SelectHealth	Default	Percent of Total Billed Charges	56.05				23.01	57.23
PULMONARY SERVICE/PROCEDURE	94799	HCPCS	410	RC		both	152	129.2	Blue Cross of ID	Default	Percent of Total Billed Charges	147.44				59.28	147.44
PULMONARY SERVICE/PROCEDURE	94799	HCPCS	410	RC		both	152	129.2	Medicaid Idaho	Default	Fee Schedule	69.92				59.28	147.44
PULMONARY SERVICE/PROCEDURE	94799	HCPCS	410	RC		both	152	129.2	Medicare A ID JF	Default	Other	59.28		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	59.28	147.44
PULMONARY SERVICE/PROCEDURE	94799	HCPCS	410	RC		both	152	129.2	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		59.28	147.44
PULMONARY SERVICE/PROCEDURE	94799	HCPCS	410	RC		both	152	129.2	Regence Group Administrators	Default	Fee Schedule	147.44				59.28	147.44
PULMONARY SERVICE/PROCEDURE	94799	HCPCS	410	RC		both	152	129.2	SelectHealth	Default	Percent of Total Billed Charges	144.4				59.28	147.44
US BLADDER CAPACITY SCAN	51798	HCPCS	761	RC		both	244	207.4	Blue Cross of ID	Default	Percent of Total Billed Charges	236.68				10.13	236.68
US BLADDER CAPACITY SCAN	51798	HCPCS	761	RC		both	244	207.4	Medicaid Idaho	Default	Fee Schedule	112.24				10.13	236.68
US BLADDER CAPACITY SCAN	51798	HCPCS	761	RC		both	244	207.4	Medicare A ID JF	Default	Other	95.16		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	10.13	236.68
US BLADDER CAPACITY SCAN	51798	HCPCS	761	RC		both	244	207.4	Medicare B ID JF	Default	Fee Schedule	10.13		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		10.13	236.68
US BLADDER CAPACITY SCAN	51798	HCPCS	761	RC		both	244	207.4	Regence Group Administrators	Default	Fee Schedule	236.68				10.13	236.68
US BLADDER CAPACITY SCAN	51798	HCPCS	761	RC		both	244	207.4	SelectHealth	Default	Percent of Total Billed Charges	231.8				10.13	236.68
RT NASAL/TRACH SUCTION	31720	HCPCS	410	RC		both	184	156.4	Blue Cross of ID	Default	Percent of Total Billed Charges	178.48				45.28	178.48
RT NASAL/TRACH SUCTION	31720	HCPCS	410	RC		both	184	156.4	Medicaid Idaho	Default	Fee Schedule	84.64				45.28	178.48
RT NASAL/TRACH SUCTION	31720	HCPCS	410	RC		both	184	156.4	Medicare A ID JF	Default	Other	71.76		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	45.28	178.48
RT NASAL/TRACH SUCTION	31720	HCPCS	410	RC		both	184	156.4	Medicare B ID JF	Default	Fee Schedule	45.28		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		45.28	178.48
RT NASAL/TRACH SUCTION	31720	HCPCS	410	RC		both	184	156.4	Regence Group Administrators	Default	Fee Schedule	178.48				45.28	178.48
RT NASAL/TRACH SUCTION	31720	HCPCS	410	RC		both	184	156.4	SelectHealth	Default	Percent of Total Billed Charges	174.8				45.28	178.48
RT ARTERIAL BLOOD GAS DRAW	36600	HCPCS	300	RC		both	28.5	24.23	Blue Cross of ID	Default	Percent of Total Billed Charges	27.64				13.11	27.64
RT ARTERIAL BLOOD GAS DRAW	36600	HCPCS	300	RC		both	28.5	24.23	Medicaid Idaho	Default	Fee Schedule	13.11				13.11	27.64
RT ARTERIAL BLOOD GAS DRAW	36600	HCPCS	300	RC		both	28.5	24.23	Medicare A ID JF	Default	Other	25.47		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	13.11	27.64
RT ARTERIAL BLOOD GAS DRAW	36600	HCPCS	300	RC		both	28.5	24.23	Medicare B ID JF	Default	Fee Schedule	25.47		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		13.11	27.64
RT ARTERIAL BLOOD GAS DRAW	36600	HCPCS	300	RC		both	28.5	24.23	Regence Group Administrators	Default	Fee Schedule	27.64				13.11	27.64
RT ARTERIAL BLOOD GAS DRAW	36600	HCPCS	300	RC		both	28.5	24.23	SelectHealth	Default	Percent of Total Billed Charges	27.08				13.11	27.64
RT AEROSOL INHALATION TX FOR PNEUMONIA	94642	HCPCS	410	RC		both	191.5	162.78	Blue Cross of ID	Default	Percent of Total Billed Charges	185.76				74.69	185.76
RT AEROSOL INHALATION TX FOR PNEUMONIA	94642	HCPCS	410	RC		both	191.5	162.78	Medicaid Idaho	Default	Fee Schedule	88.09				74.69	185.76
RT AEROSOL INHALATION TX FOR PNEUMONIA	94642	HCPCS	410	RC		both	191.5	162.78	Medicare A ID JF	Default	Other	74.69		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	74.69	185.76
RT AEROSOL INHALATION TX FOR PNEUMONIA	94642	HCPCS	410	RC		both	191.5	162.78	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		74.69	185.76
RT AEROSOL INHALATION TX FOR PNEUMONIA	94642	HCPCS	410	RC		both	191.5	162.78	Regence Group Administrators	Default	Fee Schedule	185.76				74.69	185.76
RT AEROSOL INHALATION TX FOR PNEUMONIA	94642	HCPCS	410	RC		both	191.5	162.78	SelectHealth	Default	Percent of Total Billed Charges	181.92				74.69	185.76
RT CPAP/BIPAP VENT/HIGH FLOW	94660	HCPCS	410	RC		both	464.5	394.83	Blue Cross of ID	Default	Percent of Total Billed Charges	450.56				60.07	450.56
RT CPAP/BIPAP VENT/HIGH FLOW	94660	HCPCS	410	RC		both	464.5	394.83	Medicaid Idaho	Default	Fee Schedule	213.67				60.07	450.56
RT CPAP/BIPAP VENT/HIGH FLOW	94660	HCPCS	410	RC		both	464.5	394.83	Medicare A ID JF	Default	Other	181.16		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	60.07	450.56
RT CPAP/BIPAP VENT/HIGH FLOW	94660	HCPCS	410	RC		both	464.5	394.83	Medicare B ID JF	Default	Fee Schedule	60.07		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		60.07	450.56
RT CPAP/BIPAP VENT/HIGH FLOW	94660	HCPCS	410	RC		both	464.5	394.83	Regence Group Administrators	Default	Fee Schedule	450.56				60.07	450.56
RT CPAP/BIPAP VENT/HIGH FLOW	94660	HCPCS	410	RC		both	464.5	394.83	SelectHealth	Default	Percent of Total Billed Charges	441.28				60.07	450.56
RT CHEST WALL MANIPULATION INITL	94667	HCPCS	410	RC		both	107	90.95	Blue Cross of ID	Default	Percent of Total Billed Charges	103.79				22.37	103.79
RT CHEST WALL MANIPULATION INITL	94667	HCPCS	410	RC		both	107	90.95	Medicaid Idaho	Default	Fee Schedule	49.22				22.37	103.79
RT CHEST WALL MANIPULATION INITL	94667	HCPCS	410	RC		both	107	90.95	Medicare A ID JF	Default	Other	41.73		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	22.37	103.79
RT CHEST WALL MANIPULATION INITL	94667	HCPCS	410	RC		both	107	90.95	Medicare B ID JF	Default	Fee Schedule	22.37		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		22.37	103.79
RT CHEST WALL MANIPULATION INITL	94667	HCPCS	410	RC		both	107	90.95	Regence Group Administrators	Default	Fee Schedule	103.79				22.37	103.79
RT CHEST WALL MANIPULATION INITL	94667	HCPCS	410	RC		both	107	90.95	SelectHealth	Default	Percent of Total Billed Charges	101.65				22.37	103.79
RT INCENT SPIROMETY TEACH/TREATMENT	270	RC				both	59	50.15	Blue Cross of ID	Default	Percent of Total Billed Charges	57.23				23.01	57.23
RT INCENT SPIROMETY TEACH/TREATMENT	270	RC				both	59	50.15	Medicaid Idaho	Default	Fee Schedule	27.14				23.01	57.23
RT INCENT SPIROMETY TEACH/TREATMENT	270	RC				both	59	50.15	Medicare A ID JF	Default	Other	23.01		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	23.01	57.23
RT INCENT SPIROMETY TEACH/TREATMENT	270	RC				both	59	50.15	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		23.01	57.23
RT INCENT SPIROMETY TEACH/TREATMENT	270	RC				both	59	50.15	Regence Group Administrators	Default	Fee Schedule	57.23				23.01	57.23
RT INCENT SPIROMETY TEACH/TREATMENT	270	RC				both	59	50.15	SelectHealth	Default	Percent of Total Billed Charges	56.05				23.01	57.23
RT INCENTIVE SPIROMETER	270	RC				both	92.5	78.63	Blue Cross of ID	Default	Percent of Total Billed Charges	89.72				36.08	89.72
RT INCENTIVE SPIROMETER	270	RC				both	92.5	78.63	Medicaid Idaho	Default	Fee Schedule	42.55				36.08	89.72
RT INCENTIVE SPIROMETER	270	RC				both	92.5	78.63	Medicare A ID JF	Default	Other	36.08		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	36.08	89.72
RT INCENTIVE SPIROMETER	270	RC				both	92.5	78.63	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		36.08	89.72
RT INCENTIVE SPIROMETER	270	RC				both	92.5	78.63	Regence Group Administrators	Default	Fee Schedule	89.72				36.08	89.72
RT INCENTIVE SPIROMETER	270	RC				both	92.5	78.63	SelectHealth	Default	Percent of Total Billed Charges	87.88				36.08	89.72
RT INCUBATOR OXYGEN HOURLY	410	RC				both	60.5	51.43	Blue Cross of ID	Default	Percent of Total Billed Charges	58.68				23.6	58.68
RT INCUBATOR OXYGEN HOURLY	410	RC				both	60.5	51.43	Medicaid Idaho	Default	Fee Schedule	27.83				23.6	58.68
RT INCUBATOR OXYGEN HOURLY	410	RC				both	60.5	51.43	Medicare A ID JF	Default	Other	23.6		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	23.6	58.68
RT INCUBATOR OXYGEN HOURLY	410	RC				both	60.5	51.43	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		23.6	58.68
RT INCUBATOR OXYGEN HOURLY	410	RC				both	60.5	51.43	Regence Group Administrators	Default	Fee Schedule	58.68				23.6	58.68
RT INCUBATOR OXYGEN HOURLY	410	RC				both	60.5	51.43	SelectHealth	Default	Percent of Total Billed Charges	57.48				23.6	58.68
RT INHALATION TREATMENT	94640	HCPCS	412	RC		both	139	118.15	Blue Cross of ID	Default	Percent of Total Billed Charges	134.83				7.11	134.83
RT INHALATION TREATMENT	94640	HCPCS	412	RC		both	139	118.15	Medicaid Idaho	Default	Fee Schedule	63.94				7.11	134.83
RT INHALATION TREATMENT	94640	HCPCS	412	RC		both	139	118.15	Medicare A ID JF	Default	Other	54.21		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	7.11	134.83
RT INHALATION TREATMENT	94640	HCPCS	412	RC		both	139	118.15	Medicare B ID JF	Default	Fee Schedule	7.11		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		7.11	134.83
RT INHALATION TREATMENT	94640	HCPCS	412	RC		both	139	118.15	Regence Group Administrators	Default	Fee Schedule	134.83				7.11	134.83
RT INHALATION TREATMENT	94640	HCPCS	412	RC		both	139	118.15	SelectHealth	Default	Percent of Total Billed Charges	132.05				7.11	134.83
RT CONT INHALATION TX WITH AEROSOL 1 HR	94664	HCPCS	410	RC		both	120.5	102.43	Blue Cross of ID	Default	Percent of Total Billed Charges	116.88				16.02	116.88
RT CONT INHALATION TX WITH AEROSOL 1 HR	94664	HCPCS	410	RC		both	120.5	102.43	Medicaid Idaho	Default	Fee Schedule	55.43				16.02	116.88
RT CONT INHALATION TX WITH AEROSOL 1 HR	94664	HCPCS	410	RC		both	120.5	102.43	Medicare A ID JF	Default	Other	47		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	16.02	116.88
RT CONT INHALATION TX WITH AEROSOL 1 HR	94664	HCPCS	410	RC		both	120.5	102.43	Medicare B ID JF	Default	Fee Schedule	16.02		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		16.02	116.88
RT CONT INHALATION TX WITH AEROSOL 1 HR	94664	HCPCS	410	RC		both	120.5	102.43	Regence Group Administrators	Default	Fee Schedule	116.88				16.02	116.88
RT CONT INHALATION TX WITH AEROSOL 1 HR	94664	HCPCS	410	RC		both	120.5	102.43	SelectHealth	Default	Percent of Total Billed Charges	114.48				16.02	116.88
RT OXYGEN HOURLY	270	RC				both	34.5	29.33	Blue Cross of ID	Default	Percent of Total Billed Charges	33.46				13.46	33.46
RT OXYGEN HOURLY	270	RC				both	34.5	29.33	Medicaid Idaho	Default	Fee Schedule	15.87				13.46	33.46
RT OXYGEN HOURLY	270	RC				both	34.5	29.33	Medicare A ID JF	Default	Other	13.46		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	13.46	33.46
RT OXYGEN HOURLY	270	RC				both	34.5	29.33	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		13.46	33.46
RT OXYGEN HOURLY	270	RC				both	34.5	29.33	Regence Group Administrators	Default	Fee Schedule	33.46				13.46	33.46
RT OXYGEN HOURLY	270	RC				both	34.5	29.33	SelectHealth	Default	Percent of Total Billed Charges	32.78				13.46	33.46
RT PEAK FLOW METER	94010	HCPCS	460	RC		both	115	97.75	Blue Cross of ID	Default	Percent of Total Billed Charges	111.55				25.01	111.55
RT PEAK FLOW METER	94010	HCPCS	460	RC		both	115	97.75	Medicaid Idaho	Default	Fee Schedule	52.9				25.01	111.55
RT PEAK FLOW METER	94010	HCPCS	460	RC		both	115	97.75	Medicare A ID JF	Default	Other	44.85		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	25.01	111.55
RT PEAK FLOW METER	94010	HCPCS	460	RC		both	115	97.75	Medicare B ID JF	Default	Fee Schedule	25.01		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		25.01	111.55
RT PEAK FLOW METER	94010	HCPCS	460	RC		both	115	97.75	Regence Group Administrators	Default	Fee Schedule	111.55				25.01	111.55
RT PEAK FLOW METER	94010	HCPCS	460	RC		both	115	97.75	SelectHealth	Default	Percent of Total Billed Charges	109.25				25.01	111.55
RT PULMONARY FUNCTIONS TEST	94060	HCPCS	460	RC		both	314	266.9	Blue Cross of ID	Default	Percent of Total Billed Charges	304.58				35.74	304.58
RT PULMONARY FUNCTIONS TEST	94060	HCPCS	460	RC		both	314	266.9	Medicaid Idaho	Default	Fee Schedule	144.44				35.74	304.58
RT PULMONARY FUNCTIONS TEST	94060	HCPCS	460	RC		both	314	266.9	Medicare A ID JF	Default	Other	122.46		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	35.74	304.58
RT PULMONARY FUNCTIONS TEST	94060	HCPCS	460	RC		both	314	266.9	Medicare B ID JF	Default	Fee Schedule	35.74		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		35.74	304.58
RT PULMONARY FUNCTIONS TEST	94060	HCPCS	460	RC		both	314	266.9	Regence Group Administrators	Default	Fee Schedule	304.58				35.74	304.58
RT PULMONARY FUNCTIONS TEST	94060	HCPCS	460	RC		both	314	266.9	SelectHealth	Default	Percent of Total Billed Charges	298.3				35.74	304.58
RT SLEEP STUDY BASELINE	95810	HCPCS	740	RC		both	3264.5	2774.83	Blue Cross of ID	Default	Percent of Total Billed Charges	3166.56				569.9	3166.56
RT SLEEP STUDY BASELINE	95810	HCPCS	740	RC		both	3264.5	2774.83	Medicaid Idaho	Default	Fee Schedule	1501.67				569.9	3166.56
RT SLEEP STUDY BASELINE	95810	HCPCS	740	RC		both	3264.5	2774.83	Medicare A ID JF	Default	Other	1273.16		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	569.9	3166.56
RT SLEEP STUDY BASELINE	95810	HCPCS	740	RC		both	3264.5	2774.83	Medicare B ID JF	Default	Fee Schedule	569.9		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		569.9	3166.56
RT SLEEP STUDY BASELINE	95810	HCPCS	740	RC		both	3264.5	2774.83	Regence Group Administrators	Default	Fee Schedule	3166.56				569.9	3166.56
RT SLEEP STUDY BASELINE	95810	HCPCS	740	RC		both	3264.5	2774.83	SelectHealth	Default	Percent of Total Billed Charges	3101.28				569.9	3166.56
RT SLEEP STUDY CPAP	95811	HCPCS	740	RC		both	3589	3050.65	Blue Cross of ID	Default	Percent of Total Billed Charges	3481.33				595.6	3481.33
RT SLEEP STUDY CPAP	95811	HCPCS	740	RC		both	3589	3050.65	Medicaid Idaho	Default	Fee Schedule	1650.94				595.6	3481.33
RT SLEEP STUDY CPAP	95811	HCPCS	740	RC		both	3589	3050.65	Medicare A ID JF	Default	Other	1399.71		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	595.6	3481.33
RT SLEEP STUDY CPAP	95811	HCPCS	740	RC		both	3589	3050.65	Medicare B ID JF	Default	Fee Schedule	595.6		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		595.6	3481.33
RT SLEEP STUDY CPAP	95811	HCPCS	740	RC		both	3589	3050.65	Regence Group Administrators	Default	Fee Schedule	3481.33				595.6	3481.33
RT SLEEP STUDY CPAP	95811	HCPCS	740	RC		both	3589	3050.65	SelectHealth	Default	Percent of Total Billed Charges	3409.55				595.6	3481.33
RT VENTILATOR ASSIST MANAGEMENT 1ST DAY	94002	HCPCS	410	RC		both	1404	1193.4	Blue Cross of ID	Default	Percent of Total Billed Charges	1361.88				85.32	1361.88
RT VENTILATOR ASSIST MANAGEMENT 1ST DAY	94002	HCPCS	410	RC		both	1404	1193.4	Medicaid Idaho	Default	Fee Schedule	645.84				85.32	1361.88
RT VENTILATOR ASSIST MANAGEMENT 1ST DAY	94002	HCPCS	410	RC		both	1404	1193.4	Medicare A ID JF	Default	Other	547.56		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	85.32	1361.88
RT VENTILATOR ASSIST MANAGEMENT 1ST DAY	94002	HCPCS	410	RC		both	1404	1193.4	Medicare B ID JF	Default	Fee Schedule	85.32		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		85.32	1361.88
RT VENTILATOR ASSIST MANAGEMENT 1ST DAY	94002	HCPCS	410	RC		both	1404	1193.4	Regence Group Administrators	Default	Fee Schedule	1361.88				85.32	1361.88
RT VENTILATOR ASSIST MANAGEMENT 1ST DAY	94002	HCPCS	410	RC		both	1404	1193.4	SelectHealth	Default	Percent of Total Billed Charges	1333.8				85.32	1361.88
RT VENTILATOR ASSIST MANAGEMENT SUBSEQUE	94003	HCPCS	410	RC		both	1010	858.5	Blue Cross of ID	Default	Percent of Total Billed Charges	979.7				59.99	979.7
RT VENTILATOR ASSIST MANAGEMENT SUBSEQUE	94003	HCPCS	410	RC		both	1010	858.5	Medicaid Idaho	Default	Fee Schedule	464.6				59.99	979.7
RT VENTILATOR ASSIST MANAGEMENT SUBSEQUE	94003	HCPCS	410	RC		both	1010	858.5	Medicare A ID JF	Default	Other	393.9		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	59.99	979.7
RT VENTILATOR ASSIST MANAGEMENT SUBSEQUE	94003	HCPCS	410	RC		both	1010	858.5	Medicare B ID JF	Default	Fee Schedule	59.99		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		59.99	979.7
RT VENTILATOR ASSIST MANAGEMENT SUBSEQUE	94003	HCPCS	410	RC		both	1010	858.5	Regence Group Administrators	Default	Fee Schedule	979.7				59.99	979.7
RT VENTILATOR ASSIST MANAGEMENT SUBSEQUE	94003	HCPCS	410	RC		both	1010	858.5	SelectHealth	Default	Percent of Total Billed Charges	959.5				59.99	979.7
RT CONT INHALATION TX WITH AERO EA  ADTL	94664	HCPCS	410	RC		both	120.5	102.43	Blue Cross of ID	Default	Percent of Total Billed Charges	116.88				16.02	116.88
RT CONT INHALATION TX WITH AERO EA  ADTL	94664	HCPCS	410	RC		both	120.5	102.43	Medicaid Idaho	Default	Fee Schedule	55.43				16.02	116.88
RT CONT INHALATION TX WITH AERO EA  ADTL	94664	HCPCS	410	RC		both	120.5	102.43	Medicare A ID JF	Default	Other	47		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	16.02	116.88
RT CONT INHALATION TX WITH AERO EA  ADTL	94664	HCPCS	410	RC		both	120.5	102.43	Medicare B ID JF	Default	Fee Schedule	16.02		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		16.02	116.88
RT CONT INHALATION TX WITH AERO EA  ADTL	94664	HCPCS	410	RC		both	120.5	102.43	Regence Group Administrators	Default	Fee Schedule	116.88				16.02	116.88
RT CONT INHALATION TX WITH AERO EA  ADTL	94664	HCPCS	410	RC		both	120.5	102.43	SelectHealth	Default	Percent of Total Billed Charges	114.48				16.02	116.88
RT CPR	92950	HCPCS	410	RC		both	882.5	750.13	Blue Cross of ID	Default	Percent of Total Billed Charges	856.02				299.78	856.02
RT CPR	92950	HCPCS	410	RC		both	882.5	750.13	Medicaid Idaho	Default	Fee Schedule	405.95				299.78	856.02
RT CPR	92950	HCPCS	410	RC		both	882.5	750.13	Medicare A ID JF	Default	Other	344.18		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	299.78	856.02
RT CPR	92950	HCPCS	410	RC		both	882.5	750.13	Medicare B ID JF	Default	Fee Schedule	299.78		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		299.78	856.02
RT CPR	92950	HCPCS	410	RC		both	882.5	750.13	Regence Group Administrators	Default	Fee Schedule	856.02				299.78	856.02
RT CPR	92950	HCPCS	410	RC		both	882.5	750.13	SelectHealth	Default	Percent of Total Billed Charges	838.38				299.78	856.02
RT CHEST WALL MANIPULATION SUBSEQUENT	94668	HCPCS	410	RC		both	139	118.15	Blue Cross of ID	Default	Percent of Total Billed Charges	134.83				35.22	134.83
RT CHEST WALL MANIPULATION SUBSEQUENT	94668	HCPCS	410	RC		both	139	118.15	Medicaid Idaho	Default	Fee Schedule	63.94				35.22	134.83
RT CHEST WALL MANIPULATION SUBSEQUENT	94668	HCPCS	410	RC		both	139	118.15	Medicare A ID JF	Default	Other	54.21		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	35.22	134.83
RT CHEST WALL MANIPULATION SUBSEQUENT	94668	HCPCS	410	RC		both	139	118.15	Medicare B ID JF	Default	Fee Schedule	35.22		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		35.22	134.83
RT CHEST WALL MANIPULATION SUBSEQUENT	94668	HCPCS	410	RC		both	139	118.15	Regence Group Administrators	Default	Fee Schedule	134.83				35.22	134.83
RT CHEST WALL MANIPULATION SUBSEQUENT	94668	HCPCS	410	RC		both	139	118.15	SelectHealth	Default	Percent of Total Billed Charges	132.05				35.22	134.83
RT SAT CHECK SINGLE	94760	HCPCS	460	RC		both	96	81.6	Blue Cross of ID	Default	Percent of Total Billed Charges	93.12				2.27	93.12
RT SAT CHECK SINGLE	94760	HCPCS	460	RC		both	96	81.6	Medicaid Idaho	Default	Fee Schedule	44.16				2.27	93.12
RT SAT CHECK SINGLE	94760	HCPCS	460	RC		both	96	81.6	Medicare A ID JF	Default	Other	37.44		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	2.27	93.12
RT SAT CHECK SINGLE	94760	HCPCS	460	RC		both	96	81.6	Medicare B ID JF	Default	Fee Schedule	2.27		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		2.27	93.12
RT SAT CHECK SINGLE	94760	HCPCS	460	RC		both	96	81.6	Regence Group Administrators	Default	Fee Schedule	93.12				2.27	93.12
RT SAT CHECK SINGLE	94760	HCPCS	460	RC		both	96	81.6	SelectHealth	Default	Percent of Total Billed Charges	91.2				2.27	93.12
RT ET CO2 MONITORING	94770	HCPCS	460	RC		both	365	310.25	Blue Cross of ID	Default	Percent of Total Billed Charges	354.05				7.19	354.05
RT ET CO2 MONITORING	94770	HCPCS	460	RC		both	365	310.25	Medicaid Idaho	Default	Fee Schedule	167.9				7.19	354.05
RT ET CO2 MONITORING	94770	HCPCS	460	RC		both	365	310.25	Medicare A ID JF	Default	Other	142.35		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	7.19	354.05
RT ET CO2 MONITORING	94770	HCPCS	460	RC		both	365	310.25	Medicare B ID JF	Default	Fee Schedule	7.19		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		7.19	354.05
RT ET CO2 MONITORING	94770	HCPCS	460	RC		both	365	310.25	Regence Group Administrators	Default	Fee Schedule	354.05				7.19	354.05
RT ET CO2 MONITORING	94770	HCPCS	460	RC		both	365	310.25	SelectHealth	Default	Percent of Total Billed Charges	346.75				7.19	354.05
RT HOME SLEEP TEST	95806	HCPCS	920	RC		both	724.5	615.83	Blue Cross of ID	Default	Percent of Total Billed Charges	702.76				87.64	702.76
RT HOME SLEEP TEST	95806	HCPCS	920	RC		both	724.5	615.83	Medicaid Idaho	Default	Fee Schedule	333.27				87.64	702.76
RT HOME SLEEP TEST	95806	HCPCS	920	RC		both	724.5	615.83	Medicare A ID JF	Default	Other	282.56		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	87.64	702.76
RT HOME SLEEP TEST	95806	HCPCS	920	RC		both	724.5	615.83	Medicare B ID JF	Default	Fee Schedule	87.64		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		87.64	702.76
RT HOME SLEEP TEST	95806	HCPCS	920	RC		both	724.5	615.83	Regence Group Administrators	Default	Fee Schedule	702.76				87.64	702.76
RT HOME SLEEP TEST	95806	HCPCS	920	RC		both	724.5	615.83	SelectHealth	Default	Percent of Total Billed Charges	688.28				87.64	702.76
SARS-CoV-2 SEMI QUANT IGG ANTIBODY	86769	HCPCS	302	RC		both	69.5	59.08	Blue Cross of ID	Default	Percent of Total Billed Charges	67.42				27.11	67.42
SARS-CoV-2 SEMI QUANT IGG ANTIBODY	86769	HCPCS	302	RC		both	69.5	59.08	Medicaid Idaho	Default	Fee Schedule	31.97				27.11	67.42
SARS-CoV-2 SEMI QUANT IGG ANTIBODY	86769	HCPCS	302	RC		both	69.5	59.08	Medicare A ID JF	Default	Other	27.11		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	27.11	67.42
SARS-CoV-2 SEMI QUANT IGG ANTIBODY	86769	HCPCS	302	RC		both	69.5	59.08	Medicare B ID JF	Default	Fee Schedule	42.13		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		27.11	67.42
SARS-CoV-2 SEMI QUANT IGG ANTIBODY	86769	HCPCS	302	RC		both	69.5	59.08	Regence Group Administrators	Default	Fee Schedule	67.42				27.11	67.42
SARS-CoV-2 SEMI QUANT IGG ANTIBODY	86769	HCPCS	302	RC		both	69.5	59.08	SelectHealth	Default	Percent of Total Billed Charges	66.02				27.11	67.42
PT E-STIM UNATTENDED	97014	HCPCS	420	RC	GP	both	59.5	50.58	Blue Cross of ID	Default	Percent of Total Billed Charges	57.72				23.21	57.72
PT E-STIM UNATTENDED	97014	HCPCS	420	RC	GP	both	59.5	50.58	Medicaid Idaho	Default	Fee Schedule	27.37				23.21	57.72
PT E-STIM UNATTENDED	97014	HCPCS	420	RC	GP	both	59.5	50.58	Medicare A ID JF	Default	Other	23.21		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	23.21	57.72
PT E-STIM UNATTENDED	97014	HCPCS	420	RC	GP	both	59.5	50.58	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		23.21	57.72
PT E-STIM UNATTENDED	97014	HCPCS	420	RC	GP	both	59.5	50.58	Regence Group Administrators	Default	Fee Schedule	57.72				23.21	57.72
PT E-STIM UNATTENDED	97014	HCPCS	420	RC	GP	both	59.5	50.58	SelectHealth	Default	Percent of Total Billed Charges	56.52				23.21	57.72
PT E-STIM UNATTENDED	97014	HCPCS	420	RC		both	59.5	50.58	Blue Cross of ID	Default	Percent of Total Billed Charges	57.72				23.21	57.72
PT E-STIM UNATTENDED	97014	HCPCS	420	RC		both	59.5	50.58	Medicaid Idaho	Default	Fee Schedule	27.37				23.21	57.72
PT E-STIM UNATTENDED	97014	HCPCS	420	RC		both	59.5	50.58	Medicare A ID JF	Default	Other	23.21		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	23.21	57.72
PT E-STIM UNATTENDED	97014	HCPCS	420	RC		both	59.5	50.58	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		23.21	57.72
PT E-STIM UNATTENDED	97014	HCPCS	420	RC		both	59.5	50.58	Regence Group Administrators	Default	Fee Schedule	57.72				23.21	57.72
PT E-STIM UNATTENDED	97014	HCPCS	420	RC		both	59.5	50.58	SelectHealth	Default	Percent of Total Billed Charges	56.52				23.21	57.72
PT CARDIAC REHAB WITH MONITOR	93798	HCPCS	943	RC	GP	both	173	147.05	Blue Cross of ID	Default	Percent of Total Billed Charges	167.81				23.83	167.81
PT CARDIAC REHAB WITH MONITOR	93798	HCPCS	943	RC	GP	both	173	147.05	Medicaid Idaho	Default	Fee Schedule	79.58				23.83	167.81
PT CARDIAC REHAB WITH MONITOR	93798	HCPCS	943	RC	GP	both	173	147.05	Medicare A ID JF	Default	Other	67.47		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	23.83	167.81
PT CARDIAC REHAB WITH MONITOR	93798	HCPCS	943	RC	GP	both	173	147.05	Medicare B ID JF	Default	Fee Schedule	23.83		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		23.83	167.81
PT CARDIAC REHAB WITH MONITOR	93798	HCPCS	943	RC	GP	both	173	147.05	Regence Group Administrators	Default	Fee Schedule	167.81				23.83	167.81
PT CARDIAC REHAB WITH MONITOR	93798	HCPCS	943	RC	GP	both	173	147.05	SelectHealth	Default	Percent of Total Billed Charges	164.35				23.83	167.81
PT GAIT TRAINING THERAPY 15 MIN	97116	HCPCS	420	RC	GP	both	109.5	93.08	Blue Cross of ID	Default	Percent of Total Billed Charges	106.22				26.31	106.22
PT GAIT TRAINING THERAPY 15 MIN	97116	HCPCS	420	RC	GP	both	109.5	93.08	Medicaid Idaho	Default	Fee Schedule	26.31				26.31	106.22
PT GAIT TRAINING THERAPY 15 MIN	97116	HCPCS	420	RC	GP	both	109.5	93.08	Medicare A ID JF	Default	Other	42.71		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	26.31	106.22
PT GAIT TRAINING THERAPY 15 MIN	97116	HCPCS	420	RC	GP	both	109.5	93.08	Medicare B ID JF	Default	Fee Schedule	27.83		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		26.31	106.22
PT GAIT TRAINING THERAPY 15 MIN	97116	HCPCS	420	RC	GP	both	109.5	93.08	Regence Group Administrators	Default	Fee Schedule	106.22				26.31	106.22
PT GAIT TRAINING THERAPY 15 MIN	97116	HCPCS	420	RC	GP	both	109.5	93.08	SelectHealth	Default	Percent of Total Billed Charges	104.02				26.31	106.22
PT GAIT TRAINING THERAPY 15 MIN	97116	HCPCS	420	RC		both	109.5	93.08	Blue Cross of ID	Default	Percent of Total Billed Charges	106.22				26.31	106.22
PT GAIT TRAINING THERAPY 15 MIN	97116	HCPCS	420	RC		both	109.5	93.08	Medicaid Idaho	Default	Fee Schedule	26.31				26.31	106.22
PT GAIT TRAINING THERAPY 15 MIN	97116	HCPCS	420	RC		both	109.5	93.08	Medicare A ID JF	Default	Other	42.71		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	26.31	106.22
PT GAIT TRAINING THERAPY 15 MIN	97116	HCPCS	420	RC		both	109.5	93.08	Medicare B ID JF	Default	Fee Schedule	27.83		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		26.31	106.22
PT GAIT TRAINING THERAPY 15 MIN	97116	HCPCS	420	RC		both	109.5	93.08	Regence Group Administrators	Default	Fee Schedule	106.22				26.31	106.22
PT GAIT TRAINING THERAPY 15 MIN	97116	HCPCS	420	RC		both	109.5	93.08	SelectHealth	Default	Percent of Total Billed Charges	104.02				26.31	106.22
PT HOME HEALTH	G0151	HCPCS	421	RC	GP	both	252	214.2	Blue Cross of ID	Default	Percent of Total Billed Charges	244.44				98.28	244.44
PT HOME HEALTH	G0151	HCPCS	421	RC	GP	both	252	214.2	Medicaid Idaho	Default	Fee Schedule	115.92				98.28	244.44
PT HOME HEALTH	G0151	HCPCS	421	RC	GP	both	252	214.2	Medicare A ID JF	Default	Other	98.28		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	98.28	244.44
PT HOME HEALTH	G0151	HCPCS	421	RC	GP	both	252	214.2	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		98.28	244.44
PT HOME HEALTH	G0151	HCPCS	421	RC	GP	both	252	214.2	Regence Group Administrators	Default	Fee Schedule	244.44				98.28	244.44
PT HOME HEALTH	G0151	HCPCS	421	RC	GP	both	252	214.2	SelectHealth	Default	Percent of Total Billed Charges	239.4				98.28	244.44
PT HOME HEALTH	G0151	HCPCS	421	RC		both	252	214.2	Blue Cross of ID	Default	Percent of Total Billed Charges	244.44				98.28	244.44
PT HOME HEALTH	G0151	HCPCS	421	RC		both	252	214.2	Medicaid Idaho	Default	Fee Schedule	115.92				98.28	244.44
PT HOME HEALTH	G0151	HCPCS	421	RC		both	252	214.2	Medicare A ID JF	Default	Other	98.28		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	98.28	244.44
PT HOME HEALTH	G0151	HCPCS	421	RC		both	252	214.2	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		98.28	244.44
PT HOME HEALTH	G0151	HCPCS	421	RC		both	252	214.2	Regence Group Administrators	Default	Fee Schedule	244.44				98.28	244.44
PT HOME HEALTH	G0151	HCPCS	421	RC		both	252	214.2	SelectHealth	Default	Percent of Total Billed Charges	239.4				98.28	244.44
PT HOME HEALTH ASSIST	G0157	HCPCS	571	RC		both	246	209.1	Blue Cross of ID	Default	Percent of Total Billed Charges	238.62				95.94	238.62
PT HOME HEALTH ASSIST	G0157	HCPCS	571	RC		both	246	209.1	Medicaid Idaho	Default	Fee Schedule	113.16				95.94	238.62
PT HOME HEALTH ASSIST	G0157	HCPCS	571	RC		both	246	209.1	Medicare A ID JF	Default	Other	95.94		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	95.94	238.62
PT HOME HEALTH ASSIST	G0157	HCPCS	571	RC		both	246	209.1	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		95.94	238.62
PT HOME HEALTH ASSIST	G0157	HCPCS	571	RC		both	246	209.1	Regence Group Administrators	Default	Fee Schedule	238.62				95.94	238.62
PT HOME HEALTH ASSIST	G0157	HCPCS	571	RC		both	246	209.1	SelectHealth	Default	Percent of Total Billed Charges	233.7				95.94	238.62
PT IONTOPHORESIS 15 MIN	97033	HCPCS	420	RC	GP	both	205	174.25	Blue Cross of ID	Default	Percent of Total Billed Charges	198.85				18.18	198.85
PT IONTOPHORESIS 15 MIN	97033	HCPCS	420	RC	GP	both	205	174.25	Medicaid Idaho	Default	Fee Schedule	94.3				18.18	198.85
PT IONTOPHORESIS 15 MIN	97033	HCPCS	420	RC	GP	both	205	174.25	Medicare A ID JF	Default	Other	79.95		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	18.18	198.85
PT IONTOPHORESIS 15 MIN	97033	HCPCS	420	RC	GP	both	205	174.25	Medicare B ID JF	Default	Fee Schedule	18.18		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		18.18	198.85
PT IONTOPHORESIS 15 MIN	97033	HCPCS	420	RC	GP	both	205	174.25	Regence Group Administrators	Default	Fee Schedule	198.85				18.18	198.85
PT IONTOPHORESIS 15 MIN	97033	HCPCS	420	RC	GP	both	205	174.25	SelectHealth	Default	Percent of Total Billed Charges	194.75				18.18	198.85
PT IONTOPHORESIS 15 MIN	97033	HCPCS	420	RC		both	205	174.25	Blue Cross of ID	Default	Percent of Total Billed Charges	198.85				18.18	198.85
PT IONTOPHORESIS 15 MIN	97033	HCPCS	420	RC		both	205	174.25	Medicaid Idaho	Default	Fee Schedule	94.3				18.18	198.85
PT IONTOPHORESIS 15 MIN	97033	HCPCS	420	RC		both	205	174.25	Medicare A ID JF	Default	Other	79.95		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	18.18	198.85
PT IONTOPHORESIS 15 MIN	97033	HCPCS	420	RC		both	205	174.25	Medicare B ID JF	Default	Fee Schedule	18.18		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		18.18	198.85
PT IONTOPHORESIS 15 MIN	97033	HCPCS	420	RC		both	205	174.25	Regence Group Administrators	Default	Fee Schedule	198.85				18.18	198.85
PT IONTOPHORESIS 15 MIN	97033	HCPCS	420	RC		both	205	174.25	SelectHealth	Default	Percent of Total Billed Charges	194.75				18.18	198.85
PT MANUAL THERAPY TECHNIQUES 15 MIN	97140	HCPCS	420	RC	GP	both	122.5	104.13	Blue Cross of ID	Default	Percent of Total Billed Charges	118.82				24.33	118.82
PT MANUAL THERAPY TECHNIQUES 15 MIN	97140	HCPCS	420	RC	GP	both	122.5	104.13	Medicaid Idaho	Default	Fee Schedule	24.33				24.33	118.82
PT MANUAL THERAPY TECHNIQUES 15 MIN	97140	HCPCS	420	RC	GP	both	122.5	104.13	Medicare A ID JF	Default	Other	47.78		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	24.33	118.82
PT MANUAL THERAPY TECHNIQUES 15 MIN	97140	HCPCS	420	RC	GP	both	122.5	104.13	Medicare B ID JF	Default	Fee Schedule	25.65		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		24.33	118.82
PT MANUAL THERAPY TECHNIQUES 15 MIN	97140	HCPCS	420	RC	GP	both	122.5	104.13	Regence Group Administrators	Default	Fee Schedule	118.82				24.33	118.82
PT MANUAL THERAPY TECHNIQUES 15 MIN	97140	HCPCS	420	RC	GP	both	122.5	104.13	SelectHealth	Default	Percent of Total Billed Charges	116.38				24.33	118.82
PT MANUAL THERAPY TECHNIQUES 15 MIN	97140	HCPCS	420	RC		both	122.5	104.13	Blue Cross of ID	Default	Percent of Total Billed Charges	118.82				24.33	118.82
PT MANUAL THERAPY TECHNIQUES 15 MIN	97140	HCPCS	420	RC		both	122.5	104.13	Medicaid Idaho	Default	Fee Schedule	24.33				24.33	118.82
PT MANUAL THERAPY TECHNIQUES 15 MIN	97140	HCPCS	420	RC		both	122.5	104.13	Medicare A ID JF	Default	Other	47.78		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	24.33	118.82
PT MANUAL THERAPY TECHNIQUES 15 MIN	97140	HCPCS	420	RC		both	122.5	104.13	Medicare B ID JF	Default	Fee Schedule	25.65		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		24.33	118.82
PT MANUAL THERAPY TECHNIQUES 15 MIN	97140	HCPCS	420	RC		both	122.5	104.13	Regence Group Administrators	Default	Fee Schedule	118.82				24.33	118.82
PT MANUAL THERAPY TECHNIQUES 15 MIN	97140	HCPCS	420	RC		both	122.5	104.13	SelectHealth	Default	Percent of Total Billed Charges	116.38				24.33	118.82
PT MASSAGE 15 MIN	97124	HCPCS	420	RC	GP	both	109.5	93.08	Blue Cross of ID	Default	Percent of Total Billed Charges	106.22				28.43	106.22
PT MASSAGE 15 MIN	97124	HCPCS	420	RC	GP	both	109.5	93.08	Medicaid Idaho	Default	Fee Schedule	50.37				28.43	106.22
PT MASSAGE 15 MIN	97124	HCPCS	420	RC	GP	both	109.5	93.08	Medicare A ID JF	Default	Other	42.71		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	28.43	106.22
PT MASSAGE 15 MIN	97124	HCPCS	420	RC	GP	both	109.5	93.08	Medicare B ID JF	Default	Fee Schedule	28.43		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		28.43	106.22
PT MASSAGE 15 MIN	97124	HCPCS	420	RC	GP	both	109.5	93.08	Regence Group Administrators	Default	Fee Schedule	106.22				28.43	106.22
PT MASSAGE 15 MIN	97124	HCPCS	420	RC	GP	both	109.5	93.08	SelectHealth	Default	Percent of Total Billed Charges	104.02				28.43	106.22
PT MASSAGE 15 MIN	97124	HCPCS	420	RC		both	109.5	93.08	Blue Cross of ID	Default	Percent of Total Billed Charges	106.22				28.43	106.22
PT MASSAGE 15 MIN	97124	HCPCS	420	RC		both	109.5	93.08	Medicaid Idaho	Default	Fee Schedule	50.37				28.43	106.22
PT MASSAGE 15 MIN	97124	HCPCS	420	RC		both	109.5	93.08	Medicare A ID JF	Default	Other	42.71		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	28.43	106.22
PT MASSAGE 15 MIN	97124	HCPCS	420	RC		both	109.5	93.08	Medicare B ID JF	Default	Fee Schedule	28.43		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		28.43	106.22
PT MASSAGE 15 MIN	97124	HCPCS	420	RC		both	109.5	93.08	Regence Group Administrators	Default	Fee Schedule	106.22				28.43	106.22
PT MASSAGE 15 MIN	97124	HCPCS	420	RC		both	109.5	93.08	SelectHealth	Default	Percent of Total Billed Charges	104.02				28.43	106.22
PT NEUROMUSCULAR RE-EDUCATION	97112	HCPCS	420	RC	GP	both	122.5	104.13	Blue Cross of ID	Default	Percent of Total Billed Charges	118.82				30.27	118.82
PT NEUROMUSCULAR RE-EDUCATION	97112	HCPCS	420	RC	GP	both	122.5	104.13	Medicaid Idaho	Default	Fee Schedule	30.27				30.27	118.82
PT NEUROMUSCULAR RE-EDUCATION	97112	HCPCS	420	RC	GP	both	122.5	104.13	Medicare A ID JF	Default	Other	47.78		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	30.27	118.82
PT NEUROMUSCULAR RE-EDUCATION	97112	HCPCS	420	RC	GP	both	122.5	104.13	Medicare B ID JF	Default	Fee Schedule	31.91		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		30.27	118.82
PT NEUROMUSCULAR RE-EDUCATION	97112	HCPCS	420	RC	GP	both	122.5	104.13	Regence Group Administrators	Default	Fee Schedule	118.82				30.27	118.82
PT NEUROMUSCULAR RE-EDUCATION	97112	HCPCS	420	RC	GP	both	122.5	104.13	SelectHealth	Default	Percent of Total Billed Charges	116.38				30.27	118.82
PT NEUROMUSCULAR RE-EDUCATION	97112	HCPCS	420	RC		both	122.5	104.13	Blue Cross of ID	Default	Percent of Total Billed Charges	118.82				30.27	118.82
PT NEUROMUSCULAR RE-EDUCATION	97112	HCPCS	420	RC		both	122.5	104.13	Medicaid Idaho	Default	Fee Schedule	30.27				30.27	118.82
PT NEUROMUSCULAR RE-EDUCATION	97112	HCPCS	420	RC		both	122.5	104.13	Medicare A ID JF	Default	Other	47.78		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	30.27	118.82
PT NEUROMUSCULAR RE-EDUCATION	97112	HCPCS	420	RC		both	122.5	104.13	Medicare B ID JF	Default	Fee Schedule	31.91		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		30.27	118.82
PT NEUROMUSCULAR RE-EDUCATION	97112	HCPCS	420	RC		both	122.5	104.13	Regence Group Administrators	Default	Fee Schedule	118.82				30.27	118.82
PT NEUROMUSCULAR RE-EDUCATION	97112	HCPCS	420	RC		both	122.5	104.13	SelectHealth	Default	Percent of Total Billed Charges	116.38				30.27	118.82
PT THERAPEUTIC ACTIVITIES 15 MIN	97530	HCPCS	420	RC	GP	both	142.5	121.13	Blue Cross of ID	Default	Percent of Total Billed Charges	138.22				33.67	138.22
PT THERAPEUTIC ACTIVITIES 15 MIN	97530	HCPCS	420	RC	GP	both	142.5	121.13	Medicaid Idaho	Default	Fee Schedule	33.67				33.67	138.22
PT THERAPEUTIC ACTIVITIES 15 MIN	97530	HCPCS	420	RC	GP	both	142.5	121.13	Medicare A ID JF	Default	Other	55.58		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	33.67	138.22
PT THERAPEUTIC ACTIVITIES 15 MIN	97530	HCPCS	420	RC	GP	both	142.5	121.13	Medicare B ID JF	Default	Fee Schedule	34.45		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		33.67	138.22
PT THERAPEUTIC ACTIVITIES 15 MIN	97530	HCPCS	420	RC	GP	both	142.5	121.13	Regence Group Administrators	Default	Fee Schedule	138.22				33.67	138.22
PT THERAPEUTIC ACTIVITIES 15 MIN	97530	HCPCS	420	RC	GP	both	142.5	121.13	SelectHealth	Default	Percent of Total Billed Charges	135.38				33.67	138.22
PT THERAPEUTIC ACTIVITIES 15 MIN	97530	HCPCS	420	RC		both	142.5	121.13	Blue Cross of ID	Default	Percent of Total Billed Charges	138.22				33.67	138.22
PT THERAPEUTIC ACTIVITIES 15 MIN	97530	HCPCS	420	RC		both	142.5	121.13	Medicaid Idaho	Default	Fee Schedule	33.67				33.67	138.22
PT THERAPEUTIC ACTIVITIES 15 MIN	97530	HCPCS	420	RC		both	142.5	121.13	Medicare A ID JF	Default	Other	55.58		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	33.67	138.22
PT THERAPEUTIC ACTIVITIES 15 MIN	97530	HCPCS	420	RC		both	142.5	121.13	Medicare B ID JF	Default	Fee Schedule	34.45		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		33.67	138.22
PT THERAPEUTIC ACTIVITIES 15 MIN	97530	HCPCS	420	RC		both	142.5	121.13	Regence Group Administrators	Default	Fee Schedule	138.22				33.67	138.22
PT THERAPEUTIC ACTIVITIES 15 MIN	97530	HCPCS	420	RC		both	142.5	121.13	SelectHealth	Default	Percent of Total Billed Charges	135.38				33.67	138.22
PT THERAPEUTIC PROCEDURE 15 MIN	97110	HCPCS	420	RC	GP	both	114.5	97.33	Blue Cross of ID	Default	Percent of Total Billed Charges	111.06				26.48	111.06
PT THERAPEUTIC PROCEDURE 15 MIN	97110	HCPCS	420	RC	GP	both	114.5	97.33	Medicaid Idaho	Default	Fee Schedule	26.48				26.48	111.06
PT THERAPEUTIC PROCEDURE 15 MIN	97110	HCPCS	420	RC	GP	both	114.5	97.33	Medicare A ID JF	Default	Other	44.66		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	26.48	111.06
PT THERAPEUTIC PROCEDURE 15 MIN	97110	HCPCS	420	RC	GP	both	114.5	97.33	Medicare B ID JF	Default	Fee Schedule	27.83		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		26.48	111.06
PT THERAPEUTIC PROCEDURE 15 MIN	97110	HCPCS	420	RC	GP	both	114.5	97.33	Regence Group Administrators	Default	Fee Schedule	111.06				26.48	111.06
PT THERAPEUTIC PROCEDURE 15 MIN	97110	HCPCS	420	RC	GP	both	114.5	97.33	SelectHealth	Default	Percent of Total Billed Charges	108.78				26.48	111.06
PT THERAPEUTIC PROCEDURE 15 MIN	97110	HCPCS	420	RC		both	114.5	97.33	Blue Cross of ID	Default	Percent of Total Billed Charges	111.06				26.48	111.06
PT THERAPEUTIC PROCEDURE 15 MIN	97110	HCPCS	420	RC		both	114.5	97.33	Medicaid Idaho	Default	Fee Schedule	26.48				26.48	111.06
PT THERAPEUTIC PROCEDURE 15 MIN	97110	HCPCS	420	RC		both	114.5	97.33	Medicare A ID JF	Default	Other	44.66		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	26.48	111.06
PT THERAPEUTIC PROCEDURE 15 MIN	97110	HCPCS	420	RC		both	114.5	97.33	Medicare B ID JF	Default	Fee Schedule	27.83		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		26.48	111.06
PT THERAPEUTIC PROCEDURE 15 MIN	97110	HCPCS	420	RC		both	114.5	97.33	Regence Group Administrators	Default	Fee Schedule	111.06				26.48	111.06
PT THERAPEUTIC PROCEDURE 15 MIN	97110	HCPCS	420	RC		both	114.5	97.33	SelectHealth	Default	Percent of Total Billed Charges	108.78				26.48	111.06
PT ULTRASOUND 15 MIN	97035	HCPCS	420	RC	GP	both	92.5	78.63	Blue Cross of ID	Default	Percent of Total Billed Charges	89.72				13.19	89.72
PT ULTRASOUND 15 MIN	97035	HCPCS	420	RC	GP	both	92.5	78.63	Medicaid Idaho	Default	Fee Schedule	42.55				13.19	89.72
PT ULTRASOUND 15 MIN	97035	HCPCS	420	RC	GP	both	92.5	78.63	Medicare A ID JF	Default	Other	36.08		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	13.19	89.72
PT ULTRASOUND 15 MIN	97035	HCPCS	420	RC	GP	both	92.5	78.63	Medicare B ID JF	Default	Fee Schedule	13.19		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		13.19	89.72
PT ULTRASOUND 15 MIN	97035	HCPCS	420	RC	GP	both	92.5	78.63	Regence Group Administrators	Default	Fee Schedule	89.72				13.19	89.72
PT ULTRASOUND 15 MIN	97035	HCPCS	420	RC	GP	both	92.5	78.63	SelectHealth	Default	Percent of Total Billed Charges	87.88				13.19	89.72
PT ULTRASOUND 15 MIN	97035	HCPCS	420	RC		both	92.5	78.63	Blue Cross of ID	Default	Percent of Total Billed Charges	89.72				13.19	89.72
PT ULTRASOUND 15 MIN	97035	HCPCS	420	RC		both	92.5	78.63	Medicaid Idaho	Default	Fee Schedule	42.55				13.19	89.72
PT ULTRASOUND 15 MIN	97035	HCPCS	420	RC		both	92.5	78.63	Medicare A ID JF	Default	Other	36.08		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	13.19	89.72
PT ULTRASOUND 15 MIN	97035	HCPCS	420	RC		both	92.5	78.63	Medicare B ID JF	Default	Fee Schedule	13.19		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		13.19	89.72
PT ULTRASOUND 15 MIN	97035	HCPCS	420	RC		both	92.5	78.63	Regence Group Administrators	Default	Fee Schedule	89.72				13.19	89.72
PT ULTRASOUND 15 MIN	97035	HCPCS	420	RC		both	92.5	78.63	SelectHealth	Default	Percent of Total Billed Charges	87.88				13.19	89.72
PT DRY NEEDLING 1-2	20560	HCPCS	420	RC	GP	both	56	47.6	Blue Cross of ID	Default	Percent of Total Billed Charges	54.32				21.84	54.32
PT DRY NEEDLING 1-2	20560	HCPCS	420	RC	GP	both	56	47.6	Medicaid Idaho	Default	Fee Schedule	25.76				21.84	54.32
PT DRY NEEDLING 1-2	20560	HCPCS	420	RC	GP	both	56	47.6	Medicare A ID JF	Default	Other	21.84		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	21.84	54.32
PT DRY NEEDLING 1-2	20560	HCPCS	420	RC	GP	both	56	47.6	Medicare B ID JF	Default	Fee Schedule	24.1		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		21.84	54.32
PT DRY NEEDLING 1-2	20560	HCPCS	420	RC	GP	both	56	47.6	Regence Group Administrators	Default	Fee Schedule	54.32				21.84	54.32
PT DRY NEEDLING 1-2	20560	HCPCS	420	RC	GP	both	56	47.6	SelectHealth	Default	Percent of Total Billed Charges	53.2				21.84	54.32
PT DRY NEEDLING 1-2	20560	HCPCS	420	RC		both	56	47.6	Blue Cross of ID	Default	Percent of Total Billed Charges	54.32				21.84	54.32
PT DRY NEEDLING 1-2	20560	HCPCS	420	RC		both	56	47.6	Medicaid Idaho	Default	Fee Schedule	25.76				21.84	54.32
PT DRY NEEDLING 1-2	20560	HCPCS	420	RC		both	56	47.6	Medicare A ID JF	Default	Other	21.84		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	21.84	54.32
PT DRY NEEDLING 1-2	20560	HCPCS	420	RC		both	56	47.6	Medicare B ID JF	Default	Fee Schedule	24.1		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		21.84	54.32
PT DRY NEEDLING 1-2	20560	HCPCS	420	RC		both	56	47.6	Regence Group Administrators	Default	Fee Schedule	54.32				21.84	54.32
PT DRY NEEDLING 1-2	20560	HCPCS	420	RC		both	56	47.6	SelectHealth	Default	Percent of Total Billed Charges	53.2				21.84	54.32
PT DRY NEEDLING 3-4	20561	HCPCS	420	RC	GP	both	80.5	68.43	Blue Cross of ID	Default	Percent of Total Billed Charges	78.08				31.4	78.08
PT DRY NEEDLING 3-4	20561	HCPCS	420	RC	GP	both	80.5	68.43	Medicaid Idaho	Default	Fee Schedule	37.03				31.4	78.08
PT DRY NEEDLING 3-4	20561	HCPCS	420	RC	GP	both	80.5	68.43	Medicare A ID JF	Default	Other	31.4		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	31.4	78.08
PT DRY NEEDLING 3-4	20561	HCPCS	420	RC	GP	both	80.5	68.43	Medicare B ID JF	Default	Fee Schedule	34.72		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		31.4	78.08
PT DRY NEEDLING 3-4	20561	HCPCS	420	RC	GP	both	80.5	68.43	Regence Group Administrators	Default	Fee Schedule	78.08				31.4	78.08
PT DRY NEEDLING 3-4	20561	HCPCS	420	RC	GP	both	80.5	68.43	SelectHealth	Default	Percent of Total Billed Charges	76.48				31.4	78.08
PT DRY NEEDLING 3-4	20561	HCPCS	420	RC		both	80.5	68.43	Blue Cross of ID	Default	Percent of Total Billed Charges	78.08				31.4	78.08
PT DRY NEEDLING 3-4	20561	HCPCS	420	RC		both	80.5	68.43	Medicaid Idaho	Default	Fee Schedule	37.03				31.4	78.08
PT DRY NEEDLING 3-4	20561	HCPCS	420	RC		both	80.5	68.43	Medicare A ID JF	Default	Other	31.4		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	31.4	78.08
PT DRY NEEDLING 3-4	20561	HCPCS	420	RC		both	80.5	68.43	Medicare B ID JF	Default	Fee Schedule	34.72		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		31.4	78.08
PT DRY NEEDLING 3-4	20561	HCPCS	420	RC		both	80.5	68.43	Regence Group Administrators	Default	Fee Schedule	78.08				31.4	78.08
PT DRY NEEDLING 3-4	20561	HCPCS	420	RC		both	80.5	68.43	SelectHealth	Default	Percent of Total Billed Charges	76.48				31.4	78.08
PT BRACE FITTING 15 MIN	97760	HCPCS	420	RC	GP	both	117.5	99.88	Blue Cross of ID	Default	Percent of Total Billed Charges	113.98				40.2	113.98
PT BRACE FITTING 15 MIN	97760	HCPCS	420	RC	GP	both	117.5	99.88	Medicaid Idaho	Default	Fee Schedule	40.2				40.2	113.98
PT BRACE FITTING 15 MIN	97760	HCPCS	420	RC	GP	both	117.5	99.88	Medicare A ID JF	Default	Other	45.83		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	40.2	113.98
PT BRACE FITTING 15 MIN	97760	HCPCS	420	RC	GP	both	117.5	99.88	Medicare B ID JF	Default	Fee Schedule	44.6		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		40.2	113.98
PT BRACE FITTING 15 MIN	97760	HCPCS	420	RC	GP	both	117.5	99.88	Regence Group Administrators	Default	Fee Schedule	113.98				40.2	113.98
PT BRACE FITTING 15 MIN	97760	HCPCS	420	RC	GP	both	117.5	99.88	SelectHealth	Default	Percent of Total Billed Charges	111.62				40.2	113.98
PT BRACE FITTING 15 MIN	97760	HCPCS	420	RC		both	117.5	99.88	Blue Cross of ID	Default	Percent of Total Billed Charges	113.98				40.2	113.98
PT BRACE FITTING 15 MIN	97760	HCPCS	420	RC		both	117.5	99.88	Medicaid Idaho	Default	Fee Schedule	40.2				40.2	113.98
PT BRACE FITTING 15 MIN	97760	HCPCS	420	RC		both	117.5	99.88	Medicare A ID JF	Default	Other	45.83		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	40.2	113.98
PT BRACE FITTING 15 MIN	97760	HCPCS	420	RC		both	117.5	99.88	Medicare B ID JF	Default	Fee Schedule	44.6		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		40.2	113.98
PT BRACE FITTING 15 MIN	97760	HCPCS	420	RC		both	117.5	99.88	Regence Group Administrators	Default	Fee Schedule	113.98				40.2	113.98
PT BRACE FITTING 15 MIN	97760	HCPCS	420	RC		both	117.5	99.88	SelectHealth	Default	Percent of Total Billed Charges	111.62				40.2	113.98
PT CANALITH REPOSITIONING PROC	95992	HCPCS	420	RC	GP	both	156.5	133.03	Blue Cross of ID	Default	Percent of Total Billed Charges	151.8				40.24	151.8
PT CANALITH REPOSITIONING PROC	95992	HCPCS	420	RC	GP	both	156.5	133.03	Medicaid Idaho	Default	Fee Schedule	71.99				40.24	151.8
PT CANALITH REPOSITIONING PROC	95992	HCPCS	420	RC	GP	both	156.5	133.03	Medicare A ID JF	Default	Other	61.04		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	40.24	151.8
PT CANALITH REPOSITIONING PROC	95992	HCPCS	420	RC	GP	both	156.5	133.03	Medicare B ID JF	Default	Fee Schedule	40.24		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		40.24	151.8
PT CANALITH REPOSITIONING PROC	95992	HCPCS	420	RC	GP	both	156.5	133.03	Regence Group Administrators	Default	Fee Schedule	151.8				40.24	151.8
PT CANALITH REPOSITIONING PROC	95992	HCPCS	420	RC	GP	both	156.5	133.03	SelectHealth	Default	Percent of Total Billed Charges	148.68				40.24	151.8
PT CANALITH REPOSITIONING PROC	95992	HCPCS	420	RC		both	156.5	133.03	Blue Cross of ID	Default	Percent of Total Billed Charges	151.8				40.24	151.8
PT CANALITH REPOSITIONING PROC	95992	HCPCS	420	RC		both	156.5	133.03	Medicaid Idaho	Default	Fee Schedule	71.99				40.24	151.8
PT CANALITH REPOSITIONING PROC	95992	HCPCS	420	RC		both	156.5	133.03	Medicare A ID JF	Default	Other	61.04		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	40.24	151.8
PT CANALITH REPOSITIONING PROC	95992	HCPCS	420	RC		both	156.5	133.03	Medicare B ID JF	Default	Fee Schedule	40.24		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		40.24	151.8
PT CANALITH REPOSITIONING PROC	95992	HCPCS	420	RC		both	156.5	133.03	Regence Group Administrators	Default	Fee Schedule	151.8				40.24	151.8
PT CANALITH REPOSITIONING PROC	95992	HCPCS	420	RC		both	156.5	133.03	SelectHealth	Default	Percent of Total Billed Charges	148.68				40.24	151.8
PT MECHANICAL TRACTION THERAPY	97012	HCPCS	420	RC	GP	both	72	61.2	Blue Cross of ID	Default	Percent of Total Billed Charges	69.84				13.31	69.84
PT MECHANICAL TRACTION THERAPY	97012	HCPCS	420	RC	GP	both	72	61.2	Medicaid Idaho	Default	Fee Schedule	33.12				13.31	69.84
PT MECHANICAL TRACTION THERAPY	97012	HCPCS	420	RC	GP	both	72	61.2	Medicare A ID JF	Default	Other	28.08		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	13.31	69.84
PT MECHANICAL TRACTION THERAPY	97012	HCPCS	420	RC	GP	both	72	61.2	Medicare B ID JF	Default	Fee Schedule	13.31		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		13.31	69.84
PT MECHANICAL TRACTION THERAPY	97012	HCPCS	420	RC	GP	both	72	61.2	Regence Group Administrators	Default	Fee Schedule	69.84				13.31	69.84
PT MECHANICAL TRACTION THERAPY	97012	HCPCS	420	RC	GP	both	72	61.2	SelectHealth	Default	Percent of Total Billed Charges	68.4				13.31	69.84
PT MECHANICAL TRACTION THERAPY	97012	HCPCS	420	RC		both	72	61.2	Blue Cross of ID	Default	Percent of Total Billed Charges	69.84				13.31	69.84
PT MECHANICAL TRACTION THERAPY	97012	HCPCS	420	RC		both	72	61.2	Medicaid Idaho	Default	Fee Schedule	33.12				13.31	69.84
PT MECHANICAL TRACTION THERAPY	97012	HCPCS	420	RC		both	72	61.2	Medicare A ID JF	Default	Other	28.08		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	13.31	69.84
PT MECHANICAL TRACTION THERAPY	97012	HCPCS	420	RC		both	72	61.2	Medicare B ID JF	Default	Fee Schedule	13.31		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		13.31	69.84
PT MECHANICAL TRACTION THERAPY	97012	HCPCS	420	RC		both	72	61.2	Regence Group Administrators	Default	Fee Schedule	69.84				13.31	69.84
PT MECHANICAL TRACTION THERAPY	97012	HCPCS	420	RC		both	72	61.2	SelectHealth	Default	Percent of Total Billed Charges	68.4				13.31	69.84
PT VASOPNEUMATIC DEVICES	97016	HCPCS	420	RC	GP	both	107	90.95	Blue Cross of ID	Default	Percent of Total Billed Charges	103.79				10.98	103.79
PT VASOPNEUMATIC DEVICES	97016	HCPCS	420	RC	GP	both	107	90.95	Medicaid Idaho	Default	Fee Schedule	49.22				10.98	103.79
PT VASOPNEUMATIC DEVICES	97016	HCPCS	420	RC	GP	both	107	90.95	Medicare A ID JF	Default	Other	41.73		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	10.98	103.79
PT VASOPNEUMATIC DEVICES	97016	HCPCS	420	RC	GP	both	107	90.95	Medicare B ID JF	Default	Fee Schedule	10.98		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		10.98	103.79
PT VASOPNEUMATIC DEVICES	97016	HCPCS	420	RC	GP	both	107	90.95	Regence Group Administrators	Default	Fee Schedule	103.79				10.98	103.79
PT VASOPNEUMATIC DEVICES	97016	HCPCS	420	RC	GP	both	107	90.95	SelectHealth	Default	Percent of Total Billed Charges	101.65				10.98	103.79
PT VASOPNEUMATIC DEVICES	97016	HCPCS	420	RC		both	107	90.95	Blue Cross of ID	Default	Percent of Total Billed Charges	103.79				10.98	103.79
PT VASOPNEUMATIC DEVICES	97016	HCPCS	420	RC		both	107	90.95	Medicaid Idaho	Default	Fee Schedule	49.22				10.98	103.79
PT VASOPNEUMATIC DEVICES	97016	HCPCS	420	RC		both	107	90.95	Medicare A ID JF	Default	Other	41.73		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	10.98	103.79
PT VASOPNEUMATIC DEVICES	97016	HCPCS	420	RC		both	107	90.95	Medicare B ID JF	Default	Fee Schedule	10.98		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		10.98	103.79
PT VASOPNEUMATIC DEVICES	97016	HCPCS	420	RC		both	107	90.95	Regence Group Administrators	Default	Fee Schedule	103.79				10.98	103.79
PT VASOPNEUMATIC DEVICES	97016	HCPCS	420	RC		both	107	90.95	SelectHealth	Default	Percent of Total Billed Charges	101.65				10.98	103.79
PT PARAFFIN BATH	97018	HCPCS	420	RC	GP	both	70	59.5	Blue Cross of ID	Default	Percent of Total Billed Charges	67.9				5.17	67.9
PT PARAFFIN BATH	97018	HCPCS	420	RC	GP	both	70	59.5	Medicaid Idaho	Default	Fee Schedule	32.2				5.17	67.9
PT PARAFFIN BATH	97018	HCPCS	420	RC	GP	both	70	59.5	Medicare A ID JF	Default	Other	27.3		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	5.17	67.9
PT PARAFFIN BATH	97018	HCPCS	420	RC	GP	both	70	59.5	Medicare B ID JF	Default	Fee Schedule	5.17		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		5.17	67.9
PT PARAFFIN BATH	97018	HCPCS	420	RC	GP	both	70	59.5	Regence Group Administrators	Default	Fee Schedule	67.9				5.17	67.9
PT PARAFFIN BATH	97018	HCPCS	420	RC	GP	both	70	59.5	SelectHealth	Default	Percent of Total Billed Charges	66.5				5.17	67.9
PT PARAFFIN BATH	97018	HCPCS	420	RC		both	70	59.5	Blue Cross of ID	Default	Percent of Total Billed Charges	67.9				5.17	67.9
PT PARAFFIN BATH	97018	HCPCS	420	RC		both	70	59.5	Medicaid Idaho	Default	Fee Schedule	32.2				5.17	67.9
PT PARAFFIN BATH	97018	HCPCS	420	RC		both	70	59.5	Medicare A ID JF	Default	Other	27.3		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	5.17	67.9
PT PARAFFIN BATH	97018	HCPCS	420	RC		both	70	59.5	Medicare B ID JF	Default	Fee Schedule	5.17		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		5.17	67.9
PT PARAFFIN BATH	97018	HCPCS	420	RC		both	70	59.5	Regence Group Administrators	Default	Fee Schedule	67.9				5.17	67.9
PT PARAFFIN BATH	97018	HCPCS	420	RC		both	70	59.5	SelectHealth	Default	Percent of Total Billed Charges	66.5				5.17	67.9
THERAPUTIC EXERCISE- 15 MIN EACH	97110	HCPCS	420	RC	GP	both	83.5	70.98	Blue Cross of ID	Default	Percent of Total Billed Charges	81				26.48	81
THERAPUTIC EXERCISE- 15 MIN EACH	97110	HCPCS	420	RC	GP	both	83.5	70.98	Medicaid Idaho	Default	Fee Schedule	26.48				26.48	81
THERAPUTIC EXERCISE- 15 MIN EACH	97110	HCPCS	420	RC	GP	both	83.5	70.98	Medicare A ID JF	Default	Other	32.57		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	26.48	81
THERAPUTIC EXERCISE- 15 MIN EACH	97110	HCPCS	420	RC	GP	both	83.5	70.98	Medicare B ID JF	Default	Fee Schedule	27.83		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		26.48	81
THERAPUTIC EXERCISE- 15 MIN EACH	97110	HCPCS	420	RC	GP	both	83.5	70.98	Regence Group Administrators	Default	Fee Schedule	81				26.48	81
THERAPUTIC EXERCISE- 15 MIN EACH	97110	HCPCS	420	RC	GP	both	83.5	70.98	SelectHealth	Default	Percent of Total Billed Charges	79.32				26.48	81
THERAPUTIC EXERCISE- 15 MIN EACH	97110	HCPCS	420	RC		both	83.5	70.98	Blue Cross of ID	Default	Percent of Total Billed Charges	81				26.48	81
THERAPUTIC EXERCISE- 15 MIN EACH	97110	HCPCS	420	RC		both	83.5	70.98	Medicaid Idaho	Default	Fee Schedule	26.48				26.48	81
THERAPUTIC EXERCISE- 15 MIN EACH	97110	HCPCS	420	RC		both	83.5	70.98	Medicare A ID JF	Default	Other	32.57		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	26.48	81
THERAPUTIC EXERCISE- 15 MIN EACH	97110	HCPCS	420	RC		both	83.5	70.98	Medicare B ID JF	Default	Fee Schedule	27.83		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		26.48	81
THERAPUTIC EXERCISE- 15 MIN EACH	97110	HCPCS	420	RC		both	83.5	70.98	Regence Group Administrators	Default	Fee Schedule	81				26.48	81
THERAPUTIC EXERCISE- 15 MIN EACH	97110	HCPCS	420	RC		both	83.5	70.98	SelectHealth	Default	Percent of Total Billed Charges	79.32				26.48	81
PT COGNITIVE FUNCTION INITIAL	97129	HCPCS	420	RC	GP	both	37.5	31.88	Blue Cross of ID	Default	Percent of Total Billed Charges	36.38				14.63	36.38
PT COGNITIVE FUNCTION INITIAL	97129	HCPCS	420	RC	GP	both	37.5	31.88	Medicaid Idaho	Default	Fee Schedule	17.25				14.63	36.38
PT COGNITIVE FUNCTION INITIAL	97129	HCPCS	420	RC	GP	both	37.5	31.88	Medicare A ID JF	Default	Other	14.63		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	14.63	36.38
PT COGNITIVE FUNCTION INITIAL	97129	HCPCS	420	RC	GP	both	37.5	31.88	Medicare B ID JF	Default	Fee Schedule	21.63		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		14.63	36.38
PT COGNITIVE FUNCTION INITIAL	97129	HCPCS	420	RC	GP	both	37.5	31.88	Regence Group Administrators	Default	Fee Schedule	36.38				14.63	36.38
PT COGNITIVE FUNCTION INITIAL	97129	HCPCS	420	RC	GP	both	37.5	31.88	SelectHealth	Default	Percent of Total Billed Charges	35.62				14.63	36.38
PT COGNITIVE FUNCTION INITIAL	97129	HCPCS	420	RC		both	37.5	31.88	Blue Cross of ID	Default	Percent of Total Billed Charges	36.38				14.63	36.38
PT COGNITIVE FUNCTION INITIAL	97129	HCPCS	420	RC		both	37.5	31.88	Medicaid Idaho	Default	Fee Schedule	17.25				14.63	36.38
PT COGNITIVE FUNCTION INITIAL	97129	HCPCS	420	RC		both	37.5	31.88	Medicare A ID JF	Default	Other	14.63		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	14.63	36.38
PT COGNITIVE FUNCTION INITIAL	97129	HCPCS	420	RC		both	37.5	31.88	Medicare B ID JF	Default	Fee Schedule	21.63		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		14.63	36.38
PT COGNITIVE FUNCTION INITIAL	97129	HCPCS	420	RC		both	37.5	31.88	Regence Group Administrators	Default	Fee Schedule	36.38				14.63	36.38
PT COGNITIVE FUNCTION INITIAL	97129	HCPCS	420	RC		both	37.5	31.88	SelectHealth	Default	Percent of Total Billed Charges	35.62				14.63	36.38
PT COGNITIVE FUNCTION ADD ON	97130	HCPCS	420	RC	GP	both	35.5	30.18	Blue Cross of ID	Default	Percent of Total Billed Charges	34.44				13.85	34.44
PT COGNITIVE FUNCTION ADD ON	97130	HCPCS	420	RC	GP	both	35.5	30.18	Medicaid Idaho	Default	Fee Schedule	16.33				13.85	34.44
PT COGNITIVE FUNCTION ADD ON	97130	HCPCS	420	RC	GP	both	35.5	30.18	Medicare A ID JF	Default	Other	13.85		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	13.85	34.44
PT COGNITIVE FUNCTION ADD ON	97130	HCPCS	420	RC	GP	both	35.5	30.18	Medicare B ID JF	Default	Fee Schedule	20.67		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		13.85	34.44
PT COGNITIVE FUNCTION ADD ON	97130	HCPCS	420	RC	GP	both	35.5	30.18	Regence Group Administrators	Default	Fee Schedule	34.44				13.85	34.44
PT COGNITIVE FUNCTION ADD ON	97130	HCPCS	420	RC	GP	both	35.5	30.18	SelectHealth	Default	Percent of Total Billed Charges	33.72				13.85	34.44
PT COGNITIVE FUNCTION ADD ON	97130	HCPCS	420	RC		both	35.5	30.18	Blue Cross of ID	Default	Percent of Total Billed Charges	34.44				13.85	34.44
PT COGNITIVE FUNCTION ADD ON	97130	HCPCS	420	RC		both	35.5	30.18	Medicaid Idaho	Default	Fee Schedule	16.33				13.85	34.44
PT COGNITIVE FUNCTION ADD ON	97130	HCPCS	420	RC		both	35.5	30.18	Medicare A ID JF	Default	Other	13.85		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	13.85	34.44
PT COGNITIVE FUNCTION ADD ON	97130	HCPCS	420	RC		both	35.5	30.18	Medicare B ID JF	Default	Fee Schedule	20.67		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		13.85	34.44
PT COGNITIVE FUNCTION ADD ON	97130	HCPCS	420	RC		both	35.5	30.18	Regence Group Administrators	Default	Fee Schedule	34.44				13.85	34.44
PT COGNITIVE FUNCTION ADD ON	97130	HCPCS	420	RC		both	35.5	30.18	SelectHealth	Default	Percent of Total Billed Charges	33.72				13.85	34.44
PT EVALUATION LOW COMPLEXITY	97161	HCPCS	424	RC	GP	both	210	178.5	Blue Cross of ID	Default	Percent of Total Billed Charges	203.7				73.85	203.7
PT EVALUATION LOW COMPLEXITY	97161	HCPCS	424	RC	GP	both	210	178.5	Medicaid Idaho	Default	Fee Schedule	73.85				73.85	203.7
PT EVALUATION LOW COMPLEXITY	97161	HCPCS	424	RC	GP	both	210	178.5	Medicare A ID JF	Default	Other	81.9		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	73.85	203.7
PT EVALUATION LOW COMPLEXITY	97161	HCPCS	424	RC	GP	both	210	178.5	Medicare B ID JF	Default	Fee Schedule	95.1		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		73.85	203.7
PT EVALUATION LOW COMPLEXITY	97161	HCPCS	424	RC	GP	both	210	178.5	Regence Group Administrators	Default	Fee Schedule	203.7				73.85	203.7
PT EVALUATION LOW COMPLEXITY	97161	HCPCS	424	RC	GP	both	210	178.5	SelectHealth	Default	Percent of Total Billed Charges	199.5				73.85	203.7
PT EVALUATION LOW COMPLEXITY	97161	HCPCS	424	RC		both	210	178.5	Blue Cross of ID	Default	Percent of Total Billed Charges	203.7				73.85	203.7
PT EVALUATION LOW COMPLEXITY	97161	HCPCS	424	RC		both	210	178.5	Medicaid Idaho	Default	Fee Schedule	73.85				73.85	203.7
PT EVALUATION LOW COMPLEXITY	97161	HCPCS	424	RC		both	210	178.5	Medicare A ID JF	Default	Other	81.9		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	73.85	203.7
PT EVALUATION LOW COMPLEXITY	97161	HCPCS	424	RC		both	210	178.5	Medicare B ID JF	Default	Fee Schedule	95.1		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		73.85	203.7
PT EVALUATION LOW COMPLEXITY	97161	HCPCS	424	RC		both	210	178.5	Regence Group Administrators	Default	Fee Schedule	203.7				73.85	203.7
PT EVALUATION LOW COMPLEXITY	97161	HCPCS	424	RC		both	210	178.5	SelectHealth	Default	Percent of Total Billed Charges	199.5				73.85	203.7
PT EVALUATION MODERATE COMPLEXITY	97162	HCPCS	424	RC	GP	both	237.5	201.88	Blue Cross of ID	Default	Percent of Total Billed Charges	230.38				73.85	230.38
PT EVALUATION MODERATE COMPLEXITY	97162	HCPCS	424	RC	GP	both	237.5	201.88	Medicaid Idaho	Default	Fee Schedule	73.85				73.85	230.38
PT EVALUATION MODERATE COMPLEXITY	97162	HCPCS	424	RC	GP	both	237.5	201.88	Medicare A ID JF	Default	Other	92.63		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	73.85	230.38
PT EVALUATION MODERATE COMPLEXITY	97162	HCPCS	424	RC	GP	both	237.5	201.88	Medicare B ID JF	Default	Fee Schedule	95.1		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		73.85	230.38
PT EVALUATION MODERATE COMPLEXITY	97162	HCPCS	424	RC	GP	both	237.5	201.88	Regence Group Administrators	Default	Fee Schedule	230.38				73.85	230.38
PT EVALUATION MODERATE COMPLEXITY	97162	HCPCS	424	RC	GP	both	237.5	201.88	SelectHealth	Default	Percent of Total Billed Charges	225.62				73.85	230.38
PT EVALUATION MODERATE COMPLEXITY	97162	HCPCS	424	RC		both	237.5	201.88	Blue Cross of ID	Default	Percent of Total Billed Charges	230.38				73.85	230.38
PT EVALUATION MODERATE COMPLEXITY	97162	HCPCS	424	RC		both	237.5	201.88	Medicaid Idaho	Default	Fee Schedule	73.85				73.85	230.38
PT EVALUATION MODERATE COMPLEXITY	97162	HCPCS	424	RC		both	237.5	201.88	Medicare A ID JF	Default	Other	92.63		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	73.85	230.38
PT EVALUATION MODERATE COMPLEXITY	97162	HCPCS	424	RC		both	237.5	201.88	Medicare B ID JF	Default	Fee Schedule	95.1		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		73.85	230.38
PT EVALUATION MODERATE COMPLEXITY	97162	HCPCS	424	RC		both	237.5	201.88	Regence Group Administrators	Default	Fee Schedule	230.38				73.85	230.38
PT EVALUATION MODERATE COMPLEXITY	97162	HCPCS	424	RC		both	237.5	201.88	SelectHealth	Default	Percent of Total Billed Charges	225.62				73.85	230.38
PT EVALUATION HIGH COMPLEXITY	97163	HCPCS	424	RC	GP	both	264.5	224.83	Blue Cross of ID	Default	Percent of Total Billed Charges	256.56				95.1	256.56
PT EVALUATION HIGH COMPLEXITY	97163	HCPCS	424	RC	GP	both	264.5	224.83	Medicaid Idaho	Default	Fee Schedule	121.67				95.1	256.56
PT EVALUATION HIGH COMPLEXITY	97163	HCPCS	424	RC	GP	both	264.5	224.83	Medicare A ID JF	Default	Other	103.16		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	95.1	256.56
PT EVALUATION HIGH COMPLEXITY	97163	HCPCS	424	RC	GP	both	264.5	224.83	Medicare B ID JF	Default	Fee Schedule	95.1		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		95.1	256.56
PT EVALUATION HIGH COMPLEXITY	97163	HCPCS	424	RC	GP	both	264.5	224.83	Regence Group Administrators	Default	Fee Schedule	256.56				95.1	256.56
PT EVALUATION HIGH COMPLEXITY	97163	HCPCS	424	RC	GP	both	264.5	224.83	SelectHealth	Default	Percent of Total Billed Charges	251.28				95.1	256.56
PT EVALUATION HIGH COMPLEXITY	97163	HCPCS	424	RC		both	264.5	224.83	Blue Cross of ID	Default	Percent of Total Billed Charges	256.56				95.1	256.56
PT EVALUATION HIGH COMPLEXITY	97163	HCPCS	424	RC		both	264.5	224.83	Medicaid Idaho	Default	Fee Schedule	121.67				95.1	256.56
PT EVALUATION HIGH COMPLEXITY	97163	HCPCS	424	RC		both	264.5	224.83	Medicare A ID JF	Default	Other	103.16		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	95.1	256.56
PT EVALUATION HIGH COMPLEXITY	97163	HCPCS	424	RC		both	264.5	224.83	Medicare B ID JF	Default	Fee Schedule	95.1		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		95.1	256.56
PT EVALUATION HIGH COMPLEXITY	97163	HCPCS	424	RC		both	264.5	224.83	Regence Group Administrators	Default	Fee Schedule	256.56				95.1	256.56
PT EVALUATION HIGH COMPLEXITY	97163	HCPCS	424	RC		both	264.5	224.83	SelectHealth	Default	Percent of Total Billed Charges	251.28				95.1	256.56
PT RE-EVALUATION	97164	HCPCS	424	RC	GP	both	226.5	192.53	Blue Cross of ID	Default	Percent of Total Billed Charges	219.7				50.54	219.7
PT RE-EVALUATION	97164	HCPCS	424	RC	GP	both	226.5	192.53	Medicaid Idaho	Default	Fee Schedule	50.54				50.54	219.7
PT RE-EVALUATION	97164	HCPCS	424	RC	GP	both	226.5	192.53	Medicare A ID JF	Default	Other	88.34		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	50.54	219.7
PT RE-EVALUATION	97164	HCPCS	424	RC	GP	both	226.5	192.53	Medicare B ID JF	Default	Fee Schedule	65.66		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		50.54	219.7
PT RE-EVALUATION	97164	HCPCS	424	RC	GP	both	226.5	192.53	Regence Group Administrators	Default	Fee Schedule	219.7				50.54	219.7
PT RE-EVALUATION	97164	HCPCS	424	RC	GP	both	226.5	192.53	SelectHealth	Default	Percent of Total Billed Charges	215.18				50.54	219.7
PT RE-EVALUATION	97164	HCPCS	424	RC		both	226.5	192.53	Blue Cross of ID	Default	Percent of Total Billed Charges	219.7				50.54	219.7
PT RE-EVALUATION	97164	HCPCS	424	RC		both	226.5	192.53	Medicaid Idaho	Default	Fee Schedule	50.54				50.54	219.7
PT RE-EVALUATION	97164	HCPCS	424	RC		both	226.5	192.53	Medicare A ID JF	Default	Other	88.34		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	50.54	219.7
PT RE-EVALUATION	97164	HCPCS	424	RC		both	226.5	192.53	Medicare B ID JF	Default	Fee Schedule	65.66		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		50.54	219.7
PT RE-EVALUATION	97164	HCPCS	424	RC		both	226.5	192.53	Regence Group Administrators	Default	Fee Schedule	219.7				50.54	219.7
PT RE-EVALUATION	97164	HCPCS	424	RC		both	226.5	192.53	SelectHealth	Default	Percent of Total Billed Charges	215.18				50.54	219.7
PT COMMUNITY/WORK REINTEGRATION TRAINING	97537	HCPCS	420	RC	GP	both	97	82.45	Blue Cross of ID	Default	Percent of Total Billed Charges	94.09				30.03	94.09
PT COMMUNITY/WORK REINTEGRATION TRAINING	97537	HCPCS	420	RC	GP	both	97	82.45	Medicaid Idaho	Default	Fee Schedule	44.62				30.03	94.09
PT COMMUNITY/WORK REINTEGRATION TRAINING	97537	HCPCS	420	RC	GP	both	97	82.45	Medicare A ID JF	Default	Other	37.83		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	30.03	94.09
PT COMMUNITY/WORK REINTEGRATION TRAINING	97537	HCPCS	420	RC	GP	both	97	82.45	Medicare B ID JF	Default	Fee Schedule	30.03		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		30.03	94.09
PT COMMUNITY/WORK REINTEGRATION TRAINING	97537	HCPCS	420	RC	GP	both	97	82.45	Regence Group Administrators	Default	Fee Schedule	94.09				30.03	94.09
PT COMMUNITY/WORK REINTEGRATION TRAINING	97537	HCPCS	420	RC	GP	both	97	82.45	SelectHealth	Default	Percent of Total Billed Charges	92.15				30.03	94.09
PT COMMUNITY/WORK REINTEGRATION TRAINING	97537	HCPCS	420	RC		both	97	82.45	Blue Cross of ID	Default	Percent of Total Billed Charges	94.09				30.03	94.09
PT COMMUNITY/WORK REINTEGRATION TRAINING	97537	HCPCS	420	RC		both	97	82.45	Medicaid Idaho	Default	Fee Schedule	44.62				30.03	94.09
PT COMMUNITY/WORK REINTEGRATION TRAINING	97537	HCPCS	420	RC		both	97	82.45	Medicare A ID JF	Default	Other	37.83		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	30.03	94.09
PT COMMUNITY/WORK REINTEGRATION TRAINING	97537	HCPCS	420	RC		both	97	82.45	Medicare B ID JF	Default	Fee Schedule	30.03		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		30.03	94.09
PT COMMUNITY/WORK REINTEGRATION TRAINING	97537	HCPCS	420	RC		both	97	82.45	Regence Group Administrators	Default	Fee Schedule	94.09				30.03	94.09
PT COMMUNITY/WORK REINTEGRATION TRAINING	97537	HCPCS	420	RC		both	97	82.45	SelectHealth	Default	Percent of Total Billed Charges	92.15				30.03	94.09
PT WHEELCHAIR MANAGE 15 MIN	97542	HCPCS	420	RC	GP	both	93.5	79.48	Blue Cross of ID	Default	Percent of Total Billed Charges	90.7				30.03	90.7
PT WHEELCHAIR MANAGE 15 MIN	97542	HCPCS	420	RC	GP	both	93.5	79.48	Medicaid Idaho	Default	Fee Schedule	43.01				30.03	90.7
PT WHEELCHAIR MANAGE 15 MIN	97542	HCPCS	420	RC	GP	both	93.5	79.48	Medicare A ID JF	Default	Other	36.47		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	30.03	90.7
PT WHEELCHAIR MANAGE 15 MIN	97542	HCPCS	420	RC	GP	both	93.5	79.48	Medicare B ID JF	Default	Fee Schedule	30.03		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		30.03	90.7
PT WHEELCHAIR MANAGE 15 MIN	97542	HCPCS	420	RC	GP	both	93.5	79.48	Regence Group Administrators	Default	Fee Schedule	90.7				30.03	90.7
PT WHEELCHAIR MANAGE 15 MIN	97542	HCPCS	420	RC	GP	both	93.5	79.48	SelectHealth	Default	Percent of Total Billed Charges	88.82				30.03	90.7
PT WHEELCHAIR MANAGE 15 MIN	97542	HCPCS	420	RC		both	93.5	79.48	Blue Cross of ID	Default	Percent of Total Billed Charges	90.7				30.03	90.7
PT WHEELCHAIR MANAGE 15 MIN	97542	HCPCS	420	RC		both	93.5	79.48	Medicaid Idaho	Default	Fee Schedule	43.01				30.03	90.7
PT WHEELCHAIR MANAGE 15 MIN	97542	HCPCS	420	RC		both	93.5	79.48	Medicare A ID JF	Default	Other	36.47		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	30.03	90.7
PT WHEELCHAIR MANAGE 15 MIN	97542	HCPCS	420	RC		both	93.5	79.48	Medicare B ID JF	Default	Fee Schedule	30.03		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		30.03	90.7
PT WHEELCHAIR MANAGE 15 MIN	97542	HCPCS	420	RC		both	93.5	79.48	Regence Group Administrators	Default	Fee Schedule	90.7				30.03	90.7
PT WHEELCHAIR MANAGE 15 MIN	97542	HCPCS	420	RC		both	93.5	79.48	SelectHealth	Default	Percent of Total Billed Charges	88.82				30.03	90.7
PT DEBRIDMENT WOUND	97597	HCPCS	420	RC	GP	both	82	69.7	Blue Cross of ID	Default	Percent of Total Billed Charges	79.54				31.98	82
PT DEBRIDMENT WOUND	97597	HCPCS	420	RC	GP	both	82	69.7	Medicaid Idaho	Default	Fee Schedule	37.72				31.98	82
PT DEBRIDMENT WOUND	97597	HCPCS	420	RC	GP	both	82	69.7	Medicare A ID JF	Default	Other	31.98		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	31.98	82
PT DEBRIDMENT WOUND	97597	HCPCS	420	RC	GP	both	82	69.7	Medicare B ID JF	Default	Fee Schedule	82		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		31.98	82
PT DEBRIDMENT WOUND	97597	HCPCS	420	RC	GP	both	82	69.7	Regence Group Administrators	Default	Fee Schedule	79.54				31.98	82
PT DEBRIDMENT WOUND	97597	HCPCS	420	RC	GP	both	82	69.7	SelectHealth	Default	Percent of Total Billed Charges	77.9				31.98	82
PT DEBRIDMENT WOUND	97597	HCPCS	420	RC		both	82	69.7	Blue Cross of ID	Default	Percent of Total Billed Charges	79.54				31.98	82
PT DEBRIDMENT WOUND	97597	HCPCS	420	RC		both	82	69.7	Medicaid Idaho	Default	Fee Schedule	37.72				31.98	82
PT DEBRIDMENT WOUND	97597	HCPCS	420	RC		both	82	69.7	Medicare A ID JF	Default	Other	31.98		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	31.98	82
PT DEBRIDMENT WOUND	97597	HCPCS	420	RC		both	82	69.7	Medicare B ID JF	Default	Fee Schedule	82		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		31.98	82
PT DEBRIDMENT WOUND	97597	HCPCS	420	RC		both	82	69.7	Regence Group Administrators	Default	Fee Schedule	79.54				31.98	82
PT DEBRIDMENT WOUND	97597	HCPCS	420	RC		both	82	69.7	SelectHealth	Default	Percent of Total Billed Charges	77.9				31.98	82
PT PHYSICAL PERFORMANCE TEST	97750	HCPCS	420	RC	GP	both	147.5	125.38	Blue Cross of ID	Default	Percent of Total Billed Charges	143.08				32.06	143.08
PT PHYSICAL PERFORMANCE TEST	97750	HCPCS	420	RC	GP	both	147.5	125.38	Medicaid Idaho	Default	Fee Schedule	67.85				32.06	143.08
PT PHYSICAL PERFORMANCE TEST	97750	HCPCS	420	RC	GP	both	147.5	125.38	Medicare A ID JF	Default	Other	57.53		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	32.06	143.08
PT PHYSICAL PERFORMANCE TEST	97750	HCPCS	420	RC	GP	both	147.5	125.38	Medicare B ID JF	Default	Fee Schedule	32.06		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		32.06	143.08
PT PHYSICAL PERFORMANCE TEST	97750	HCPCS	420	RC	GP	both	147.5	125.38	Regence Group Administrators	Default	Fee Schedule	143.08				32.06	143.08
PT PHYSICAL PERFORMANCE TEST	97750	HCPCS	420	RC	GP	both	147.5	125.38	SelectHealth	Default	Percent of Total Billed Charges	140.12				32.06	143.08
PT PHYSICAL PERFORMANCE TEST	97750	HCPCS	420	RC		both	147.5	125.38	Blue Cross of ID	Default	Percent of Total Billed Charges	143.08				32.06	143.08
PT PHYSICAL PERFORMANCE TEST	97750	HCPCS	420	RC		both	147.5	125.38	Medicaid Idaho	Default	Fee Schedule	67.85				32.06	143.08
PT PHYSICAL PERFORMANCE TEST	97750	HCPCS	420	RC		both	147.5	125.38	Medicare A ID JF	Default	Other	57.53		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	32.06	143.08
PT PHYSICAL PERFORMANCE TEST	97750	HCPCS	420	RC		both	147.5	125.38	Medicare B ID JF	Default	Fee Schedule	32.06		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		32.06	143.08
PT PHYSICAL PERFORMANCE TEST	97750	HCPCS	420	RC		both	147.5	125.38	Regence Group Administrators	Default	Fee Schedule	143.08				32.06	143.08
PT PHYSICAL PERFORMANCE TEST	97750	HCPCS	420	RC		both	147.5	125.38	SelectHealth	Default	Percent of Total Billed Charges	140.12				32.06	143.08
PT MEDICAL TEAM CONFERENCE 30 MIN	99366	HCPCS	420	RC	GP	both	78	66.3	Blue Cross of ID	Default	Percent of Total Billed Charges	75.66				30.42	75.66
PT MEDICAL TEAM CONFERENCE 30 MIN	99366	HCPCS	420	RC	GP	both	78	66.3	Medicaid Idaho	Default	Fee Schedule	35.88				30.42	75.66
PT MEDICAL TEAM CONFERENCE 30 MIN	99366	HCPCS	420	RC	GP	both	78	66.3	Medicare A ID JF	Default	Other	30.42		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	30.42	75.66
PT MEDICAL TEAM CONFERENCE 30 MIN	99366	HCPCS	420	RC	GP	both	78	66.3	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		30.42	75.66
PT MEDICAL TEAM CONFERENCE 30 MIN	99366	HCPCS	420	RC	GP	both	78	66.3	Regence Group Administrators	Default	Fee Schedule	75.66				30.42	75.66
PT MEDICAL TEAM CONFERENCE 30 MIN	99366	HCPCS	420	RC	GP	both	78	66.3	SelectHealth	Default	Percent of Total Billed Charges	74.1				30.42	75.66
PT MEDICAL TEAM CONFERENCE 30 MIN	99366	HCPCS	420	RC		both	78	66.3	Blue Cross of ID	Default	Percent of Total Billed Charges	75.66				30.42	75.66
PT MEDICAL TEAM CONFERENCE 30 MIN	99366	HCPCS	420	RC		both	78	66.3	Medicaid Idaho	Default	Fee Schedule	35.88				30.42	75.66
PT MEDICAL TEAM CONFERENCE 30 MIN	99366	HCPCS	420	RC		both	78	66.3	Medicare A ID JF	Default	Other	30.42		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	30.42	75.66
PT MEDICAL TEAM CONFERENCE 30 MIN	99366	HCPCS	420	RC		both	78	66.3	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		30.42	75.66
PT MEDICAL TEAM CONFERENCE 30 MIN	99366	HCPCS	420	RC		both	78	66.3	Regence Group Administrators	Default	Fee Schedule	75.66				30.42	75.66
PT MEDICAL TEAM CONFERENCE 30 MIN	99366	HCPCS	420	RC		both	78	66.3	SelectHealth	Default	Percent of Total Billed Charges	74.1				30.42	75.66
OT HH VISIT	G0152	HCPCS	431	RC	GO	both	301	255.85	Blue Cross of ID	Default	Percent of Total Billed Charges	291.97				117.39	291.97
OT HH VISIT	G0152	HCPCS	431	RC	GO	both	301	255.85	Medicaid Idaho	Default	Fee Schedule	138.46				117.39	291.97
OT HH VISIT	G0152	HCPCS	431	RC	GO	both	301	255.85	Medicare A ID JF	Default	Other	117.39		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	117.39	291.97
OT HH VISIT	G0152	HCPCS	431	RC	GO	both	301	255.85	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		117.39	291.97
OT HH VISIT	G0152	HCPCS	431	RC	GO	both	301	255.85	Regence Group Administrators	Default	Fee Schedule	291.97				117.39	291.97
OT HH VISIT	G0152	HCPCS	431	RC	GO	both	301	255.85	SelectHealth	Default	Percent of Total Billed Charges	285.95				117.39	291.97
OT HH VISIT	G0152	HCPCS	431	RC		both	301	255.85	Blue Cross of ID	Default	Percent of Total Billed Charges	291.97				117.39	291.97
OT HH VISIT	G0152	HCPCS	431	RC		both	301	255.85	Medicaid Idaho	Default	Fee Schedule	138.46				117.39	291.97
OT HH VISIT	G0152	HCPCS	431	RC		both	301	255.85	Medicare A ID JF	Default	Other	117.39		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	117.39	291.97
OT HH VISIT	G0152	HCPCS	431	RC		both	301	255.85	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		117.39	291.97
OT HH VISIT	G0152	HCPCS	431	RC		both	301	255.85	Regence Group Administrators	Default	Fee Schedule	291.97				117.39	291.97
OT HH VISIT	G0152	HCPCS	431	RC		both	301	255.85	SelectHealth	Default	Percent of Total Billed Charges	285.95				117.39	291.97
"TRICHOMONAS VAGINALIS, NAA (URINE)"	87661	HCPCS	301	RC		both	58	49.3	Blue Cross of ID	Default	Percent of Total Billed Charges	56.26				22.62	58
"TRICHOMONAS VAGINALIS, NAA (URINE)"	87661	HCPCS	301	RC		both	58	49.3	Medicaid Idaho	Default	Fee Schedule	39				22.62	58
"TRICHOMONAS VAGINALIS, NAA (URINE)"	87661	HCPCS	301	RC		both	58	49.3	Medicare A ID JF	Default	Other	22.62		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	22.62	58
"TRICHOMONAS VAGINALIS, NAA (URINE)"	87661	HCPCS	301	RC		both	58	49.3	Medicare B ID JF	Default	Fee Schedule	35.09		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		22.62	58
"TRICHOMONAS VAGINALIS, NAA (URINE)"	87661	HCPCS	301	RC		both	58	49.3	Regence Group Administrators	Default	Fee Schedule	58				22.62	58
"TRICHOMONAS VAGINALIS, NAA (URINE)"	87661	HCPCS	301	RC		both	58	49.3	SelectHealth	Default	Percent of Total Billed Charges	55.1				22.62	58
ST SPEECH/ HEARING THERAPY	92507	HCPCS	441	RC	GN	both	261	221.85	Blue Cross of ID	Default	Percent of Total Billed Charges	253.17				68.99	253.17
ST SPEECH/ HEARING THERAPY	92507	HCPCS	441	RC	GN	both	261	221.85	Medicaid Idaho	Default	Fee Schedule	68.99				68.99	253.17
ST SPEECH/ HEARING THERAPY	92507	HCPCS	441	RC	GN	both	261	221.85	Medicare A ID JF	Default	Other	101.79		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	68.99	253.17
ST SPEECH/ HEARING THERAPY	92507	HCPCS	441	RC	GN	both	261	221.85	Medicare B ID JF	Default	Fee Schedule	72.75		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		68.99	253.17
ST SPEECH/ HEARING THERAPY	92507	HCPCS	441	RC	GN	both	261	221.85	Regence Group Administrators	Default	Fee Schedule	253.17				68.99	253.17
ST SPEECH/ HEARING THERAPY	92507	HCPCS	441	RC	GN	both	261	221.85	SelectHealth	Default	Percent of Total Billed Charges	247.95				68.99	253.17
ST SPEECH/ HEARING THERAPY	92507	HCPCS	441	RC		both	261	221.85	Blue Cross of ID	Default	Percent of Total Billed Charges	253.17				68.99	253.17
ST SPEECH/ HEARING THERAPY	92507	HCPCS	441	RC		both	261	221.85	Medicaid Idaho	Default	Fee Schedule	68.99				68.99	253.17
ST SPEECH/ HEARING THERAPY	92507	HCPCS	441	RC		both	261	221.85	Medicare A ID JF	Default	Other	101.79		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	68.99	253.17
ST SPEECH/ HEARING THERAPY	92507	HCPCS	441	RC		both	261	221.85	Medicare B ID JF	Default	Fee Schedule	72.75		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		68.99	253.17
ST SPEECH/ HEARING THERAPY	92507	HCPCS	441	RC		both	261	221.85	Regence Group Administrators	Default	Fee Schedule	253.17				68.99	253.17
ST SPEECH/ HEARING THERAPY	92507	HCPCS	441	RC		both	261	221.85	SelectHealth	Default	Percent of Total Billed Charges	247.95				68.99	253.17
ST EVAL OF SPEECH FLUENCY	92521	HCPCS	444	RC	GN	both	323.5	274.98	Blue Cross of ID	Default	Percent of Total Billed Charges	313.8				126.17	313.8
ST EVAL OF SPEECH FLUENCY	92521	HCPCS	444	RC	GN	both	323.5	274.98	Medicaid Idaho	Default	Fee Schedule	148.81				126.17	313.8
ST EVAL OF SPEECH FLUENCY	92521	HCPCS	444	RC	GN	both	323.5	274.98	Medicare A ID JF	Default	Other	126.17		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	126.17	313.8
ST EVAL OF SPEECH FLUENCY	92521	HCPCS	444	RC	GN	both	323.5	274.98	Medicare B ID JF	Default	Fee Schedule	126.57		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		126.17	313.8
ST EVAL OF SPEECH FLUENCY	92521	HCPCS	444	RC	GN	both	323.5	274.98	Regence Group Administrators	Default	Fee Schedule	313.8				126.17	313.8
ST EVAL OF SPEECH FLUENCY	92521	HCPCS	444	RC	GN	both	323.5	274.98	SelectHealth	Default	Percent of Total Billed Charges	307.32				126.17	313.8
ST EVAL OF SPEECH FLUENCY	92521	HCPCS	444	RC		both	323.5	274.98	Blue Cross of ID	Default	Percent of Total Billed Charges	313.8				126.17	313.8
ST EVAL OF SPEECH FLUENCY	92521	HCPCS	444	RC		both	323.5	274.98	Medicaid Idaho	Default	Fee Schedule	148.81				126.17	313.8
ST EVAL OF SPEECH FLUENCY	92521	HCPCS	444	RC		both	323.5	274.98	Medicare A ID JF	Default	Other	126.17		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	126.17	313.8
ST EVAL OF SPEECH FLUENCY	92521	HCPCS	444	RC		both	323.5	274.98	Medicare B ID JF	Default	Fee Schedule	126.57		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		126.17	313.8
ST EVAL OF SPEECH FLUENCY	92521	HCPCS	444	RC		both	323.5	274.98	Regence Group Administrators	Default	Fee Schedule	313.8				126.17	313.8
ST EVAL OF SPEECH FLUENCY	92521	HCPCS	444	RC		both	323.5	274.98	SelectHealth	Default	Percent of Total Billed Charges	307.32				126.17	313.8
ST EVAL OF SPEECH SOUND/PRODUCTION	92522	HCPCS	444	RC	GN	both	268.5	228.23	Blue Cross of ID	Default	Percent of Total Billed Charges	260.44				79.99	260.44
ST EVAL OF SPEECH SOUND/PRODUCTION	92522	HCPCS	444	RC	GN	both	268.5	228.23	Medicaid Idaho	Default	Fee Schedule	79.99				79.99	260.44
ST EVAL OF SPEECH SOUND/PRODUCTION	92522	HCPCS	444	RC	GN	both	268.5	228.23	Medicare A ID JF	Default	Other	104.72		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	79.99	260.44
ST EVAL OF SPEECH SOUND/PRODUCTION	92522	HCPCS	444	RC	GN	both	268.5	228.23	Medicare B ID JF	Default	Fee Schedule	105.79		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		79.99	260.44
ST EVAL OF SPEECH SOUND/PRODUCTION	92522	HCPCS	444	RC	GN	both	268.5	228.23	Regence Group Administrators	Default	Fee Schedule	260.44				79.99	260.44
ST EVAL OF SPEECH SOUND/PRODUCTION	92522	HCPCS	444	RC	GN	both	268.5	228.23	SelectHealth	Default	Percent of Total Billed Charges	255.08				79.99	260.44
ST EVAL OF SPEECH SOUND/PRODUCTION	92522	HCPCS	444	RC		both	268.5	228.23	Blue Cross of ID	Default	Percent of Total Billed Charges	260.44				79.99	260.44
ST EVAL OF SPEECH SOUND/PRODUCTION	92522	HCPCS	444	RC		both	268.5	228.23	Medicaid Idaho	Default	Fee Schedule	79.99				79.99	260.44
ST EVAL OF SPEECH SOUND/PRODUCTION	92522	HCPCS	444	RC		both	268.5	228.23	Medicare A ID JF	Default	Other	104.72		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	79.99	260.44
ST EVAL OF SPEECH SOUND/PRODUCTION	92522	HCPCS	444	RC		both	268.5	228.23	Medicare B ID JF	Default	Fee Schedule	105.79		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		79.99	260.44
ST EVAL OF SPEECH SOUND/PRODUCTION	92522	HCPCS	444	RC		both	268.5	228.23	Regence Group Administrators	Default	Fee Schedule	260.44				79.99	260.44
ST EVAL OF SPEECH SOUND/PRODUCTION	92522	HCPCS	444	RC		both	268.5	228.23	SelectHealth	Default	Percent of Total Billed Charges	255.08				79.99	260.44
ST EVAL OF SPCH VALUA & LANG COMP/EXP	92523	HCPCS	444	RC	GN	both	546	464.1	Blue Cross of ID	Default	Percent of Total Billed Charges	529.62				168.19	529.62
ST EVAL OF SPCH VALUA & LANG COMP/EXP	92523	HCPCS	444	RC	GN	both	546	464.1	Medicaid Idaho	Default	Fee Schedule	168.19				168.19	529.62
ST EVAL OF SPCH VALUA & LANG COMP/EXP	92523	HCPCS	444	RC	GN	both	546	464.1	Medicare A ID JF	Default	Other	212.94		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	168.19	529.62
ST EVAL OF SPCH VALUA & LANG COMP/EXP	92523	HCPCS	444	RC	GN	both	546	464.1	Medicare B ID JF	Default	Fee Schedule	217.01		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		168.19	529.62
ST EVAL OF SPCH VALUA & LANG COMP/EXP	92523	HCPCS	444	RC	GN	both	546	464.1	Regence Group Administrators	Default	Fee Schedule	529.62				168.19	529.62
ST EVAL OF SPCH VALUA & LANG COMP/EXP	92523	HCPCS	444	RC	GN	both	546	464.1	SelectHealth	Default	Percent of Total Billed Charges	518.7				168.19	529.62
ST EVAL OF SPCH VALUA & LANG COMP/EXP	92523	HCPCS	444	RC		both	546	464.1	Blue Cross of ID	Default	Percent of Total Billed Charges	529.62				168.19	529.62
ST EVAL OF SPCH VALUA & LANG COMP/EXP	92523	HCPCS	444	RC		both	546	464.1	Medicaid Idaho	Default	Fee Schedule	168.19				168.19	529.62
ST EVAL OF SPCH VALUA & LANG COMP/EXP	92523	HCPCS	444	RC		both	546	464.1	Medicare A ID JF	Default	Other	212.94		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	168.19	529.62
ST EVAL OF SPCH VALUA & LANG COMP/EXP	92523	HCPCS	444	RC		both	546	464.1	Medicare B ID JF	Default	Fee Schedule	217.01		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		168.19	529.62
ST EVAL OF SPCH VALUA & LANG COMP/EXP	92523	HCPCS	444	RC		both	546	464.1	Regence Group Administrators	Default	Fee Schedule	529.62				168.19	529.62
ST EVAL OF SPCH VALUA & LANG COMP/EXP	92523	HCPCS	444	RC		both	546	464.1	SelectHealth	Default	Percent of Total Billed Charges	518.7				168.19	529.62
ST BH QAUL ANYLYSIS OF VOICE/REASON	92524	HCPCS	444	RC	GN	both	277.5	235.88	Blue Cross of ID	Default	Percent of Total Billed Charges	269.18				104.28	269.18
ST BH QAUL ANYLYSIS OF VOICE/REASON	92524	HCPCS	444	RC	GN	both	277.5	235.88	Medicaid Idaho	Default	Fee Schedule	127.65				104.28	269.18
ST BH QAUL ANYLYSIS OF VOICE/REASON	92524	HCPCS	444	RC	GN	both	277.5	235.88	Medicare A ID JF	Default	Other	108.23		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	104.28	269.18
ST BH QAUL ANYLYSIS OF VOICE/REASON	92524	HCPCS	444	RC	GN	both	277.5	235.88	Medicare B ID JF	Default	Fee Schedule	104.28		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		104.28	269.18
ST BH QAUL ANYLYSIS OF VOICE/REASON	92524	HCPCS	444	RC	GN	both	277.5	235.88	Regence Group Administrators	Default	Fee Schedule	269.18				104.28	269.18
ST BH QAUL ANYLYSIS OF VOICE/REASON	92524	HCPCS	444	RC	GN	both	277.5	235.88	SelectHealth	Default	Percent of Total Billed Charges	263.62				104.28	269.18
ST BH QAUL ANYLYSIS OF VOICE/REASON	92524	HCPCS	444	RC		both	277.5	235.88	Blue Cross of ID	Default	Percent of Total Billed Charges	269.18				104.28	269.18
ST BH QAUL ANYLYSIS OF VOICE/REASON	92524	HCPCS	444	RC		both	277.5	235.88	Medicaid Idaho	Default	Fee Schedule	127.65				104.28	269.18
ST BH QAUL ANYLYSIS OF VOICE/REASON	92524	HCPCS	444	RC		both	277.5	235.88	Medicare A ID JF	Default	Other	108.23		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	104.28	269.18
ST BH QAUL ANYLYSIS OF VOICE/REASON	92524	HCPCS	444	RC		both	277.5	235.88	Medicare B ID JF	Default	Fee Schedule	104.28		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		104.28	269.18
ST BH QAUL ANYLYSIS OF VOICE/REASON	92524	HCPCS	444	RC		both	277.5	235.88	Regence Group Administrators	Default	Fee Schedule	269.18				104.28	269.18
ST BH QAUL ANYLYSIS OF VOICE/REASON	92524	HCPCS	444	RC		both	277.5	235.88	SelectHealth	Default	Percent of Total Billed Charges	263.62				104.28	269.18
ST ORAL FUNCTION THERAPY	92526	HCPCS	440	RC	GN	both	300.5	255.43	Blue Cross of ID	Default	Percent of Total Billed Charges	291.48				80.43	291.48
ST ORAL FUNCTION THERAPY	92526	HCPCS	440	RC	GN	both	300.5	255.43	Medicaid Idaho	Default	Fee Schedule	138.23				80.43	291.48
ST ORAL FUNCTION THERAPY	92526	HCPCS	440	RC	GN	both	300.5	255.43	Medicare A ID JF	Default	Other	117.2		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	80.43	291.48
ST ORAL FUNCTION THERAPY	92526	HCPCS	440	RC	GN	both	300.5	255.43	Medicare B ID JF	Default	Fee Schedule	80.43		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		80.43	291.48
ST ORAL FUNCTION THERAPY	92526	HCPCS	440	RC	GN	both	300.5	255.43	Regence Group Administrators	Default	Fee Schedule	291.48				80.43	291.48
ST ORAL FUNCTION THERAPY	92526	HCPCS	440	RC	GN	both	300.5	255.43	SelectHealth	Default	Percent of Total Billed Charges	285.48				80.43	291.48
ST ORAL FUNCTION THERAPY	92526	HCPCS	440	RC		both	300.5	255.43	Blue Cross of ID	Default	Percent of Total Billed Charges	291.48				80.43	291.48
ST ORAL FUNCTION THERAPY	92526	HCPCS	440	RC		both	300.5	255.43	Medicaid Idaho	Default	Fee Schedule	138.23				80.43	291.48
ST ORAL FUNCTION THERAPY	92526	HCPCS	440	RC		both	300.5	255.43	Medicare A ID JF	Default	Other	117.2		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	80.43	291.48
ST ORAL FUNCTION THERAPY	92526	HCPCS	440	RC		both	300.5	255.43	Medicare B ID JF	Default	Fee Schedule	80.43		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		80.43	291.48
ST ORAL FUNCTION THERAPY	92526	HCPCS	440	RC		both	300.5	255.43	Regence Group Administrators	Default	Fee Schedule	291.48				80.43	291.48
ST ORAL FUNCTION THERAPY	92526	HCPCS	440	RC		both	300.5	255.43	SelectHealth	Default	Percent of Total Billed Charges	285.48				80.43	291.48
ST EVAL SWALLOWING FUNCTION	92610	HCPCS	444	RC	GN	both	300.5	255.43	Blue Cross of ID	Default	Percent of Total Billed Charges	291.48				80.76	291.48
ST EVAL SWALLOWING FUNCTION	92610	HCPCS	444	RC	GN	both	300.5	255.43	Medicaid Idaho	Default	Fee Schedule	138.23				80.76	291.48
ST EVAL SWALLOWING FUNCTION	92610	HCPCS	444	RC	GN	both	300.5	255.43	Medicare A ID JF	Default	Other	117.2		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	80.76	291.48
ST EVAL SWALLOWING FUNCTION	92610	HCPCS	444	RC	GN	both	300.5	255.43	Medicare B ID JF	Default	Fee Schedule	80.76		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		80.76	291.48
ST EVAL SWALLOWING FUNCTION	92610	HCPCS	444	RC	GN	both	300.5	255.43	Regence Group Administrators	Default	Fee Schedule	291.48				80.76	291.48
ST EVAL SWALLOWING FUNCTION	92610	HCPCS	444	RC	GN	both	300.5	255.43	SelectHealth	Default	Percent of Total Billed Charges	285.48				80.76	291.48
ST EVAL SWALLOWING FUNCTION	92610	HCPCS	444	RC		both	300.5	255.43	Blue Cross of ID	Default	Percent of Total Billed Charges	291.48				80.76	291.48
ST EVAL SWALLOWING FUNCTION	92610	HCPCS	444	RC		both	300.5	255.43	Medicaid Idaho	Default	Fee Schedule	138.23				80.76	291.48
ST EVAL SWALLOWING FUNCTION	92610	HCPCS	444	RC		both	300.5	255.43	Medicare A ID JF	Default	Other	117.2		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	80.76	291.48
ST EVAL SWALLOWING FUNCTION	92610	HCPCS	444	RC		both	300.5	255.43	Medicare B ID JF	Default	Fee Schedule	80.76		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		80.76	291.48
ST EVAL SWALLOWING FUNCTION	92610	HCPCS	444	RC		both	300.5	255.43	Regence Group Administrators	Default	Fee Schedule	291.48				80.76	291.48
ST EVAL SWALLOWING FUNCTION	92610	HCPCS	444	RC		both	300.5	255.43	SelectHealth	Default	Percent of Total Billed Charges	285.48				80.76	291.48
ST ASSESSMENT OF APHASIA	96105	HCPCS	440	RC	GN	both	300.5	255.43	Blue Cross of ID	Default	Percent of Total Billed Charges	291.48				91.37	291.48
ST ASSESSMENT OF APHASIA	96105	HCPCS	440	RC	GN	both	300.5	255.43	Medicaid Idaho	Default	Fee Schedule	138.23				91.37	291.48
ST ASSESSMENT OF APHASIA	96105	HCPCS	440	RC	GN	both	300.5	255.43	Medicare A ID JF	Default	Other	117.2		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	91.37	291.48
ST ASSESSMENT OF APHASIA	96105	HCPCS	440	RC	GN	both	300.5	255.43	Medicare B ID JF	Default	Fee Schedule	91.37		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		91.37	291.48
ST ASSESSMENT OF APHASIA	96105	HCPCS	440	RC	GN	both	300.5	255.43	Regence Group Administrators	Default	Fee Schedule	291.48				91.37	291.48
ST ASSESSMENT OF APHASIA	96105	HCPCS	440	RC	GN	both	300.5	255.43	SelectHealth	Default	Percent of Total Billed Charges	285.48				91.37	291.48
ST ASSESSMENT OF APHASIA	96105	HCPCS	440	RC		both	300.5	255.43	Blue Cross of ID	Default	Percent of Total Billed Charges	291.48				91.37	291.48
ST ASSESSMENT OF APHASIA	96105	HCPCS	440	RC		both	300.5	255.43	Medicaid Idaho	Default	Fee Schedule	138.23				91.37	291.48
ST ASSESSMENT OF APHASIA	96105	HCPCS	440	RC		both	300.5	255.43	Medicare A ID JF	Default	Other	117.2		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	91.37	291.48
ST ASSESSMENT OF APHASIA	96105	HCPCS	440	RC		both	300.5	255.43	Medicare B ID JF	Default	Fee Schedule	91.37		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		91.37	291.48
ST ASSESSMENT OF APHASIA	96105	HCPCS	440	RC		both	300.5	255.43	Regence Group Administrators	Default	Fee Schedule	291.48				91.37	291.48
ST ASSESSMENT OF APHASIA	96105	HCPCS	440	RC		both	300.5	255.43	SelectHealth	Default	Percent of Total Billed Charges	285.48				91.37	291.48
OT DEVELOPMENTAL SCREEN W/SCORE &DOC STD	96110	HCPCS	430	RC	GO	both	21	17.85	Blue Cross of ID	Default	Percent of Total Billed Charges	20.37				8.19	20.37
OT DEVELOPMENTAL SCREEN W/SCORE &DOC STD	96110	HCPCS	430	RC	GO	both	21	17.85	Medicaid Idaho	Default	Fee Schedule	9.66				8.19	20.37
OT DEVELOPMENTAL SCREEN W/SCORE &DOC STD	96110	HCPCS	430	RC	GO	both	21	17.85	Medicare A ID JF	Default	Other	8.19		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	8.19	20.37
OT DEVELOPMENTAL SCREEN W/SCORE &DOC STD	96110	HCPCS	430	RC	GO	both	21	17.85	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		8.19	20.37
OT DEVELOPMENTAL SCREEN W/SCORE &DOC STD	96110	HCPCS	430	RC	GO	both	21	17.85	Regence Group Administrators	Default	Fee Schedule	20.37				8.19	20.37
OT DEVELOPMENTAL SCREEN W/SCORE &DOC STD	96110	HCPCS	430	RC	GO	both	21	17.85	SelectHealth	Default	Percent of Total Billed Charges	19.95				8.19	20.37
OT DEVELOPMENTAL SCREEN W/SCORE &DOC STD	96110	HCPCS	430	RC		both	21	17.85	Blue Cross of ID	Default	Percent of Total Billed Charges	20.37				8.19	20.37
OT DEVELOPMENTAL SCREEN W/SCORE &DOC STD	96110	HCPCS	430	RC		both	21	17.85	Medicaid Idaho	Default	Fee Schedule	9.66				8.19	20.37
OT DEVELOPMENTAL SCREEN W/SCORE &DOC STD	96110	HCPCS	430	RC		both	21	17.85	Medicare A ID JF	Default	Other	8.19		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	8.19	20.37
OT DEVELOPMENTAL SCREEN W/SCORE &DOC STD	96110	HCPCS	430	RC		both	21	17.85	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		8.19	20.37
OT DEVELOPMENTAL SCREEN W/SCORE &DOC STD	96110	HCPCS	430	RC		both	21	17.85	Regence Group Administrators	Default	Fee Schedule	20.37				8.19	20.37
OT DEVELOPMENTAL SCREEN W/SCORE &DOC STD	96110	HCPCS	430	RC		both	21	17.85	SelectHealth	Default	Percent of Total Billed Charges	19.95				8.19	20.37
ST STANDARD COGNITIVE TESTING	96125	HCPCS	430	RC	GO	both	305.5	259.68	Blue Cross of ID	Default	Percent of Total Billed Charges	296.34				97.1	296.34
ST STANDARD COGNITIVE TESTING	96125	HCPCS	430	RC	GO	both	305.5	259.68	Medicaid Idaho	Default	Fee Schedule	140.53				97.1	296.34
ST STANDARD COGNITIVE TESTING	96125	HCPCS	430	RC	GO	both	305.5	259.68	Medicare A ID JF	Default	Other	119.15		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	97.1	296.34
ST STANDARD COGNITIVE TESTING	96125	HCPCS	430	RC	GO	both	305.5	259.68	Medicare B ID JF	Default	Fee Schedule	97.1		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		97.1	296.34
ST STANDARD COGNITIVE TESTING	96125	HCPCS	430	RC	GO	both	305.5	259.68	Regence Group Administrators	Default	Fee Schedule	296.34				97.1	296.34
ST STANDARD COGNITIVE TESTING	96125	HCPCS	430	RC	GO	both	305.5	259.68	SelectHealth	Default	Percent of Total Billed Charges	290.22				97.1	296.34
ST STANDARD COGNITIVE TESTING	96125	HCPCS	430	RC		both	305.5	259.68	Blue Cross of ID	Default	Percent of Total Billed Charges	296.34				97.1	296.34
ST STANDARD COGNITIVE TESTING	96125	HCPCS	430	RC		both	305.5	259.68	Medicaid Idaho	Default	Fee Schedule	140.53				97.1	296.34
ST STANDARD COGNITIVE TESTING	96125	HCPCS	430	RC		both	305.5	259.68	Medicare A ID JF	Default	Other	119.15		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	97.1	296.34
ST STANDARD COGNITIVE TESTING	96125	HCPCS	430	RC		both	305.5	259.68	Medicare B ID JF	Default	Fee Schedule	97.1		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		97.1	296.34
ST STANDARD COGNITIVE TESTING	96125	HCPCS	430	RC		both	305.5	259.68	Regence Group Administrators	Default	Fee Schedule	296.34				97.1	296.34
ST STANDARD COGNITIVE TESTING	96125	HCPCS	430	RC		both	305.5	259.68	SelectHealth	Default	Percent of Total Billed Charges	290.22				97.1	296.34
OT E-STIM UNATTENDED	97014	HCPCS	430	RC	GO	both	62.5	53.13	Blue Cross of ID	Default	Percent of Total Billed Charges	60.62				24.38	60.62
OT E-STIM UNATTENDED	97014	HCPCS	430	RC	GO	both	62.5	53.13	Medicaid Idaho	Default	Fee Schedule	28.75				24.38	60.62
OT E-STIM UNATTENDED	97014	HCPCS	430	RC	GO	both	62.5	53.13	Medicare A ID JF	Default	Other	24.38		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	24.38	60.62
OT E-STIM UNATTENDED	97014	HCPCS	430	RC	GO	both	62.5	53.13	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		24.38	60.62
OT E-STIM UNATTENDED	97014	HCPCS	430	RC	GO	both	62.5	53.13	Regence Group Administrators	Default	Fee Schedule	60.62				24.38	60.62
OT E-STIM UNATTENDED	97014	HCPCS	430	RC	GO	both	62.5	53.13	SelectHealth	Default	Percent of Total Billed Charges	59.38				24.38	60.62
OT E-STIM UNATTENDED	97014	HCPCS	430	RC		both	62.5	53.13	Blue Cross of ID	Default	Percent of Total Billed Charges	60.62				24.38	60.62
OT E-STIM UNATTENDED	97014	HCPCS	430	RC		both	62.5	53.13	Medicaid Idaho	Default	Fee Schedule	28.75				24.38	60.62
OT E-STIM UNATTENDED	97014	HCPCS	430	RC		both	62.5	53.13	Medicare A ID JF	Default	Other	24.38		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	24.38	60.62
OT E-STIM UNATTENDED	97014	HCPCS	430	RC		both	62.5	53.13	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		24.38	60.62
OT E-STIM UNATTENDED	97014	HCPCS	430	RC		both	62.5	53.13	Regence Group Administrators	Default	Fee Schedule	60.62				24.38	60.62
OT E-STIM UNATTENDED	97014	HCPCS	430	RC		both	62.5	53.13	SelectHealth	Default	Percent of Total Billed Charges	59.38				24.38	60.62
OT PARAFFIN BATH	97018	HCPCS	430	RC	GO	both	73.5	62.48	Blue Cross of ID	Default	Percent of Total Billed Charges	71.3				5.17	71.3
OT PARAFFIN BATH	97018	HCPCS	430	RC	GO	both	73.5	62.48	Medicaid Idaho	Default	Fee Schedule	33.81				5.17	71.3
OT PARAFFIN BATH	97018	HCPCS	430	RC	GO	both	73.5	62.48	Medicare A ID JF	Default	Other	28.67		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	5.17	71.3
OT PARAFFIN BATH	97018	HCPCS	430	RC	GO	both	73.5	62.48	Medicare B ID JF	Default	Fee Schedule	5.17		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		5.17	71.3
OT PARAFFIN BATH	97018	HCPCS	430	RC	GO	both	73.5	62.48	Regence Group Administrators	Default	Fee Schedule	71.3				5.17	71.3
OT PARAFFIN BATH	97018	HCPCS	430	RC	GO	both	73.5	62.48	SelectHealth	Default	Percent of Total Billed Charges	69.82				5.17	71.3
OT PARAFFIN BATH	97018	HCPCS	430	RC		both	73.5	62.48	Blue Cross of ID	Default	Percent of Total Billed Charges	71.3				5.17	71.3
OT PARAFFIN BATH	97018	HCPCS	430	RC		both	73.5	62.48	Medicaid Idaho	Default	Fee Schedule	33.81				5.17	71.3
OT PARAFFIN BATH	97018	HCPCS	430	RC		both	73.5	62.48	Medicare A ID JF	Default	Other	28.67		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	5.17	71.3
OT PARAFFIN BATH	97018	HCPCS	430	RC		both	73.5	62.48	Medicare B ID JF	Default	Fee Schedule	5.17		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		5.17	71.3
OT PARAFFIN BATH	97018	HCPCS	430	RC		both	73.5	62.48	Regence Group Administrators	Default	Fee Schedule	71.3				5.17	71.3
OT PARAFFIN BATH	97018	HCPCS	430	RC		both	73.5	62.48	SelectHealth	Default	Percent of Total Billed Charges	69.82				5.17	71.3
OT IONTOPHORESIS	97033	HCPCS	430	RC	GO	both	211	179.35	Blue Cross of ID	Default	Percent of Total Billed Charges	204.67				18.18	204.67
OT IONTOPHORESIS	97033	HCPCS	430	RC	GO	both	211	179.35	Medicaid Idaho	Default	Fee Schedule	97.06				18.18	204.67
OT IONTOPHORESIS	97033	HCPCS	430	RC	GO	both	211	179.35	Medicare A ID JF	Default	Other	82.29		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	18.18	204.67
OT IONTOPHORESIS	97033	HCPCS	430	RC	GO	both	211	179.35	Medicare B ID JF	Default	Fee Schedule	18.18		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		18.18	204.67
OT IONTOPHORESIS	97033	HCPCS	430	RC	GO	both	211	179.35	Regence Group Administrators	Default	Fee Schedule	204.67				18.18	204.67
OT IONTOPHORESIS	97033	HCPCS	430	RC	GO	both	211	179.35	SelectHealth	Default	Percent of Total Billed Charges	200.45				18.18	204.67
OT IONTOPHORESIS	97033	HCPCS	430	RC		both	211	179.35	Blue Cross of ID	Default	Percent of Total Billed Charges	204.67				18.18	204.67
OT IONTOPHORESIS	97033	HCPCS	430	RC		both	211	179.35	Medicaid Idaho	Default	Fee Schedule	97.06				18.18	204.67
OT IONTOPHORESIS	97033	HCPCS	430	RC		both	211	179.35	Medicare A ID JF	Default	Other	82.29		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	18.18	204.67
OT IONTOPHORESIS	97033	HCPCS	430	RC		both	211	179.35	Medicare B ID JF	Default	Fee Schedule	18.18		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		18.18	204.67
OT IONTOPHORESIS	97033	HCPCS	430	RC		both	211	179.35	Regence Group Administrators	Default	Fee Schedule	204.67				18.18	204.67
OT IONTOPHORESIS	97033	HCPCS	430	RC		both	211	179.35	SelectHealth	Default	Percent of Total Billed Charges	200.45				18.18	204.67
OT CONTRAST BATH THERAPY	97034	HCPCS	430	RC	GO	both	76	64.6	Blue Cross of ID	Default	Percent of Total Billed Charges	73.72				13.19	73.72
OT CONTRAST BATH THERAPY	97034	HCPCS	430	RC	GO	both	76	64.6	Medicaid Idaho	Default	Fee Schedule	34.96				13.19	73.72
OT CONTRAST BATH THERAPY	97034	HCPCS	430	RC	GO	both	76	64.6	Medicare A ID JF	Default	Other	29.64		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	13.19	73.72
OT CONTRAST BATH THERAPY	97034	HCPCS	430	RC	GO	both	76	64.6	Medicare B ID JF	Default	Fee Schedule	13.19		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		13.19	73.72
OT CONTRAST BATH THERAPY	97034	HCPCS	430	RC	GO	both	76	64.6	Regence Group Administrators	Default	Fee Schedule	73.72				13.19	73.72
OT CONTRAST BATH THERAPY	97034	HCPCS	430	RC	GO	both	76	64.6	SelectHealth	Default	Percent of Total Billed Charges	72.2				13.19	73.72
OT CONTRAST BATH THERAPY	97034	HCPCS	430	RC		both	76	64.6	Blue Cross of ID	Default	Percent of Total Billed Charges	73.72				13.19	73.72
OT CONTRAST BATH THERAPY	97034	HCPCS	430	RC		both	76	64.6	Medicaid Idaho	Default	Fee Schedule	34.96				13.19	73.72
OT CONTRAST BATH THERAPY	97034	HCPCS	430	RC		both	76	64.6	Medicare A ID JF	Default	Other	29.64		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	13.19	73.72
OT CONTRAST BATH THERAPY	97034	HCPCS	430	RC		both	76	64.6	Medicare B ID JF	Default	Fee Schedule	13.19		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		13.19	73.72
OT CONTRAST BATH THERAPY	97034	HCPCS	430	RC		both	76	64.6	Regence Group Administrators	Default	Fee Schedule	73.72				13.19	73.72
OT CONTRAST BATH THERAPY	97034	HCPCS	430	RC		both	76	64.6	SelectHealth	Default	Percent of Total Billed Charges	72.2				13.19	73.72
OT ULTRASOUND	97035	HCPCS	430	RC	GO	both	54.5	46.33	Blue Cross of ID	Default	Percent of Total Billed Charges	52.86				13.19	52.86
OT ULTRASOUND	97035	HCPCS	430	RC	GO	both	54.5	46.33	Medicaid Idaho	Default	Fee Schedule	25.07				13.19	52.86
OT ULTRASOUND	97035	HCPCS	430	RC	GO	both	54.5	46.33	Medicare A ID JF	Default	Other	21.26		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	13.19	52.86
OT ULTRASOUND	97035	HCPCS	430	RC	GO	both	54.5	46.33	Medicare B ID JF	Default	Fee Schedule	13.19		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		13.19	52.86
OT ULTRASOUND	97035	HCPCS	430	RC	GO	both	54.5	46.33	Regence Group Administrators	Default	Fee Schedule	52.86				13.19	52.86
OT ULTRASOUND	97035	HCPCS	430	RC	GO	both	54.5	46.33	SelectHealth	Default	Percent of Total Billed Charges	51.78				13.19	52.86
OT ULTRASOUND	97035	HCPCS	430	RC		both	54.5	46.33	Blue Cross of ID	Default	Percent of Total Billed Charges	52.86				13.19	52.86
OT ULTRASOUND	97035	HCPCS	430	RC		both	54.5	46.33	Medicaid Idaho	Default	Fee Schedule	25.07				13.19	52.86
OT ULTRASOUND	97035	HCPCS	430	RC		both	54.5	46.33	Medicare A ID JF	Default	Other	21.26		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	13.19	52.86
OT ULTRASOUND	97035	HCPCS	430	RC		both	54.5	46.33	Medicare B ID JF	Default	Fee Schedule	13.19		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		13.19	52.86
OT ULTRASOUND	97035	HCPCS	430	RC		both	54.5	46.33	Regence Group Administrators	Default	Fee Schedule	52.86				13.19	52.86
OT ULTRASOUND	97035	HCPCS	430	RC		both	54.5	46.33	SelectHealth	Default	Percent of Total Billed Charges	51.78				13.19	52.86
OT THERAPEUTIC EXERCISE EA 15 MIN	97110	HCPCS	430	RC	GO	both	118	100.3	Blue Cross of ID	Default	Percent of Total Billed Charges	114.46				26.48	114.46
OT THERAPEUTIC EXERCISE EA 15 MIN	97110	HCPCS	430	RC	GO	both	118	100.3	Medicaid Idaho	Default	Fee Schedule	26.48				26.48	114.46
OT THERAPEUTIC EXERCISE EA 15 MIN	97110	HCPCS	430	RC	GO	both	118	100.3	Medicare A ID JF	Default	Other	46.02		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	26.48	114.46
OT THERAPEUTIC EXERCISE EA 15 MIN	97110	HCPCS	430	RC	GO	both	118	100.3	Medicare B ID JF	Default	Fee Schedule	27.83		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		26.48	114.46
OT THERAPEUTIC EXERCISE EA 15 MIN	97110	HCPCS	430	RC	GO	both	118	100.3	Regence Group Administrators	Default	Fee Schedule	114.46				26.48	114.46
OT THERAPEUTIC EXERCISE EA 15 MIN	97110	HCPCS	430	RC	GO	both	118	100.3	SelectHealth	Default	Percent of Total Billed Charges	112.1				26.48	114.46
OT THERAPEUTIC EXERCISE EA 15 MIN	97110	HCPCS	430	RC		both	118	100.3	Blue Cross of ID	Default	Percent of Total Billed Charges	114.46				26.48	114.46
OT THERAPEUTIC EXERCISE EA 15 MIN	97110	HCPCS	430	RC		both	118	100.3	Medicaid Idaho	Default	Fee Schedule	26.48				26.48	114.46
OT THERAPEUTIC EXERCISE EA 15 MIN	97110	HCPCS	430	RC		both	118	100.3	Medicare A ID JF	Default	Other	46.02		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	26.48	114.46
OT THERAPEUTIC EXERCISE EA 15 MIN	97110	HCPCS	430	RC		both	118	100.3	Medicare B ID JF	Default	Fee Schedule	27.83		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		26.48	114.46
OT THERAPEUTIC EXERCISE EA 15 MIN	97110	HCPCS	430	RC		both	118	100.3	Regence Group Administrators	Default	Fee Schedule	114.46				26.48	114.46
OT THERAPEUTIC EXERCISE EA 15 MIN	97110	HCPCS	430	RC		both	118	100.3	SelectHealth	Default	Percent of Total Billed Charges	112.1				26.48	114.46
OT NEURO RE-ED	97112	HCPCS	430	RC	GO	both	120.5	102.43	Blue Cross of ID	Default	Percent of Total Billed Charges	116.88				30.27	116.88
OT NEURO RE-ED	97112	HCPCS	430	RC	GO	both	120.5	102.43	Medicaid Idaho	Default	Fee Schedule	30.27				30.27	116.88
OT NEURO RE-ED	97112	HCPCS	430	RC	GO	both	120.5	102.43	Medicare A ID JF	Default	Other	47		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	30.27	116.88
OT NEURO RE-ED	97112	HCPCS	430	RC	GO	both	120.5	102.43	Medicare B ID JF	Default	Fee Schedule	31.91		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		30.27	116.88
OT NEURO RE-ED	97112	HCPCS	430	RC	GO	both	120.5	102.43	Regence Group Administrators	Default	Fee Schedule	116.88				30.27	116.88
OT NEURO RE-ED	97112	HCPCS	430	RC	GO	both	120.5	102.43	SelectHealth	Default	Percent of Total Billed Charges	114.48				30.27	116.88
OT NEURO RE-ED	97112	HCPCS	430	RC		both	120.5	102.43	Blue Cross of ID	Default	Percent of Total Billed Charges	116.88				30.27	116.88
OT NEURO RE-ED	97112	HCPCS	430	RC		both	120.5	102.43	Medicaid Idaho	Default	Fee Schedule	30.27				30.27	116.88
OT NEURO RE-ED	97112	HCPCS	430	RC		both	120.5	102.43	Medicare A ID JF	Default	Other	47		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	30.27	116.88
OT NEURO RE-ED	97112	HCPCS	430	RC		both	120.5	102.43	Medicare B ID JF	Default	Fee Schedule	31.91		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		30.27	116.88
OT NEURO RE-ED	97112	HCPCS	430	RC		both	120.5	102.43	Regence Group Administrators	Default	Fee Schedule	116.88				30.27	116.88
OT NEURO RE-ED	97112	HCPCS	430	RC		both	120.5	102.43	SelectHealth	Default	Percent of Total Billed Charges	114.48				30.27	116.88
OT COGNITIVE FUNCTION INITIAL	97129	HCPCS	430	RC	GO	both	37.5	31.88	Blue Cross of ID	Default	Percent of Total Billed Charges	36.38				14.63	36.38
OT COGNITIVE FUNCTION INITIAL	97129	HCPCS	430	RC	GO	both	37.5	31.88	Medicaid Idaho	Default	Fee Schedule	17.25				14.63	36.38
OT COGNITIVE FUNCTION INITIAL	97129	HCPCS	430	RC	GO	both	37.5	31.88	Medicare A ID JF	Default	Other	14.63		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	14.63	36.38
OT COGNITIVE FUNCTION INITIAL	97129	HCPCS	430	RC	GO	both	37.5	31.88	Medicare B ID JF	Default	Fee Schedule	21.63		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		14.63	36.38
OT COGNITIVE FUNCTION INITIAL	97129	HCPCS	430	RC	GO	both	37.5	31.88	Regence Group Administrators	Default	Fee Schedule	36.38				14.63	36.38
OT COGNITIVE FUNCTION INITIAL	97129	HCPCS	430	RC	GO	both	37.5	31.88	SelectHealth	Default	Percent of Total Billed Charges	35.62				14.63	36.38
OT COGNITIVE FUNCTION INITIAL	97129	HCPCS	430	RC		both	37.5	31.88	Blue Cross of ID	Default	Percent of Total Billed Charges	36.38				14.63	36.38
OT COGNITIVE FUNCTION INITIAL	97129	HCPCS	430	RC		both	37.5	31.88	Medicaid Idaho	Default	Fee Schedule	17.25				14.63	36.38
OT COGNITIVE FUNCTION INITIAL	97129	HCPCS	430	RC		both	37.5	31.88	Medicare A ID JF	Default	Other	14.63		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	14.63	36.38
OT COGNITIVE FUNCTION INITIAL	97129	HCPCS	430	RC		both	37.5	31.88	Medicare B ID JF	Default	Fee Schedule	21.63		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		14.63	36.38
OT COGNITIVE FUNCTION INITIAL	97129	HCPCS	430	RC		both	37.5	31.88	Regence Group Administrators	Default	Fee Schedule	36.38				14.63	36.38
OT COGNITIVE FUNCTION INITIAL	97129	HCPCS	430	RC		both	37.5	31.88	SelectHealth	Default	Percent of Total Billed Charges	35.62				14.63	36.38
OT COGNITIVE FUNCTION ADD ON	97130	HCPCS	430	RC	GO	both	35.5	30.18	Blue Cross of ID	Default	Percent of Total Billed Charges	34.44				13.85	34.44
OT COGNITIVE FUNCTION ADD ON	97130	HCPCS	430	RC	GO	both	35.5	30.18	Medicaid Idaho	Default	Fee Schedule	16.33				13.85	34.44
OT COGNITIVE FUNCTION ADD ON	97130	HCPCS	430	RC	GO	both	35.5	30.18	Medicare A ID JF	Default	Other	13.85		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	13.85	34.44
OT COGNITIVE FUNCTION ADD ON	97130	HCPCS	430	RC	GO	both	35.5	30.18	Medicare B ID JF	Default	Fee Schedule	20.67		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		13.85	34.44
OT COGNITIVE FUNCTION ADD ON	97130	HCPCS	430	RC	GO	both	35.5	30.18	Regence Group Administrators	Default	Fee Schedule	34.44				13.85	34.44
OT COGNITIVE FUNCTION ADD ON	97130	HCPCS	430	RC	GO	both	35.5	30.18	SelectHealth	Default	Percent of Total Billed Charges	33.72				13.85	34.44
OT COGNITIVE FUNCTION ADD ON	97130	HCPCS	430	RC		both	35.5	30.18	Blue Cross of ID	Default	Percent of Total Billed Charges	34.44				13.85	34.44
OT COGNITIVE FUNCTION ADD ON	97130	HCPCS	430	RC		both	35.5	30.18	Medicaid Idaho	Default	Fee Schedule	16.33				13.85	34.44
OT COGNITIVE FUNCTION ADD ON	97130	HCPCS	430	RC		both	35.5	30.18	Medicare A ID JF	Default	Other	13.85		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	13.85	34.44
OT COGNITIVE FUNCTION ADD ON	97130	HCPCS	430	RC		both	35.5	30.18	Medicare B ID JF	Default	Fee Schedule	20.67		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		13.85	34.44
OT COGNITIVE FUNCTION ADD ON	97130	HCPCS	430	RC		both	35.5	30.18	Regence Group Administrators	Default	Fee Schedule	34.44				13.85	34.44
OT COGNITIVE FUNCTION ADD ON	97130	HCPCS	430	RC		both	35.5	30.18	SelectHealth	Default	Percent of Total Billed Charges	33.72				13.85	34.44
OT MANUAL THERAPY	97140	HCPCS	430	RC	GO	both	111.5	94.78	Blue Cross of ID	Default	Percent of Total Billed Charges	108.16				24.33	108.16
OT MANUAL THERAPY	97140	HCPCS	430	RC	GO	both	111.5	94.78	Medicaid Idaho	Default	Fee Schedule	24.33				24.33	108.16
OT MANUAL THERAPY	97140	HCPCS	430	RC	GO	both	111.5	94.78	Medicare A ID JF	Default	Other	43.49		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	24.33	108.16
OT MANUAL THERAPY	97140	HCPCS	430	RC	GO	both	111.5	94.78	Medicare B ID JF	Default	Fee Schedule	25.65		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		24.33	108.16
OT MANUAL THERAPY	97140	HCPCS	430	RC	GO	both	111.5	94.78	Regence Group Administrators	Default	Fee Schedule	108.16				24.33	108.16
OT MANUAL THERAPY	97140	HCPCS	430	RC	GO	both	111.5	94.78	SelectHealth	Default	Percent of Total Billed Charges	105.92				24.33	108.16
OT MANUAL THERAPY	97140	HCPCS	430	RC		both	111.5	94.78	Blue Cross of ID	Default	Percent of Total Billed Charges	108.16				24.33	108.16
OT MANUAL THERAPY	97140	HCPCS	430	RC		both	111.5	94.78	Medicaid Idaho	Default	Fee Schedule	24.33				24.33	108.16
OT MANUAL THERAPY	97140	HCPCS	430	RC		both	111.5	94.78	Medicare A ID JF	Default	Other	43.49		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	24.33	108.16
OT MANUAL THERAPY	97140	HCPCS	430	RC		both	111.5	94.78	Medicare B ID JF	Default	Fee Schedule	25.65		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		24.33	108.16
OT MANUAL THERAPY	97140	HCPCS	430	RC		both	111.5	94.78	Regence Group Administrators	Default	Fee Schedule	108.16				24.33	108.16
OT MANUAL THERAPY	97140	HCPCS	430	RC		both	111.5	94.78	SelectHealth	Default	Percent of Total Billed Charges	105.92				24.33	108.16
OT EVALUATION LOW COMPLEXITY	97165	HCPCS	434	RC	GO	both	241.5	205.28	Blue Cross of ID	Default	Percent of Total Billed Charges	234.26				78.17	234.26
OT EVALUATION LOW COMPLEXITY	97165	HCPCS	434	RC	GO	both	241.5	205.28	Medicaid Idaho	Default	Fee Schedule	78.17				78.17	234.26
OT EVALUATION LOW COMPLEXITY	97165	HCPCS	434	RC	GO	both	241.5	205.28	Medicare A ID JF	Default	Other	94.19		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	78.17	234.26
OT EVALUATION LOW COMPLEXITY	97165	HCPCS	434	RC	GO	both	241.5	205.28	Medicare B ID JF	Default	Fee Schedule	96.01		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		78.17	234.26
OT EVALUATION LOW COMPLEXITY	97165	HCPCS	434	RC	GO	both	241.5	205.28	Regence Group Administrators	Default	Fee Schedule	234.26				78.17	234.26
OT EVALUATION LOW COMPLEXITY	97165	HCPCS	434	RC	GO	both	241.5	205.28	SelectHealth	Default	Percent of Total Billed Charges	229.42				78.17	234.26
OT EVALUATION LOW COMPLEXITY	97165	HCPCS	434	RC		both	241.5	205.28	Blue Cross of ID	Default	Percent of Total Billed Charges	234.26				78.17	234.26
OT EVALUATION LOW COMPLEXITY	97165	HCPCS	434	RC		both	241.5	205.28	Medicaid Idaho	Default	Fee Schedule	78.17				78.17	234.26
OT EVALUATION LOW COMPLEXITY	97165	HCPCS	434	RC		both	241.5	205.28	Medicare A ID JF	Default	Other	94.19		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	78.17	234.26
OT EVALUATION LOW COMPLEXITY	97165	HCPCS	434	RC		both	241.5	205.28	Medicare B ID JF	Default	Fee Schedule	96.01		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		78.17	234.26
OT EVALUATION LOW COMPLEXITY	97165	HCPCS	434	RC		both	241.5	205.28	Regence Group Administrators	Default	Fee Schedule	234.26				78.17	234.26
OT EVALUATION LOW COMPLEXITY	97165	HCPCS	434	RC		both	241.5	205.28	SelectHealth	Default	Percent of Total Billed Charges	229.42				78.17	234.26
OT EVALUATION MODERATE COMPLEXITY	97166	HCPCS	434	RC	GO	both	269	228.65	Blue Cross of ID	Default	Percent of Total Billed Charges	260.93				96.01	260.93
OT EVALUATION MODERATE COMPLEXITY	97166	HCPCS	434	RC	GO	both	269	228.65	Medicaid Idaho	Default	Fee Schedule	123.74				96.01	260.93
OT EVALUATION MODERATE COMPLEXITY	97166	HCPCS	434	RC	GO	both	269	228.65	Medicare A ID JF	Default	Other	104.91		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	96.01	260.93
OT EVALUATION MODERATE COMPLEXITY	97166	HCPCS	434	RC	GO	both	269	228.65	Medicare B ID JF	Default	Fee Schedule	96.01		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		96.01	260.93
OT EVALUATION MODERATE COMPLEXITY	97166	HCPCS	434	RC	GO	both	269	228.65	Regence Group Administrators	Default	Fee Schedule	260.93				96.01	260.93
OT EVALUATION MODERATE COMPLEXITY	97166	HCPCS	434	RC	GO	both	269	228.65	SelectHealth	Default	Percent of Total Billed Charges	255.55				96.01	260.93
OT EVALUATION MODERATE COMPLEXITY	97166	HCPCS	434	RC		both	269	228.65	Blue Cross of ID	Default	Percent of Total Billed Charges	260.93				96.01	260.93
OT EVALUATION MODERATE COMPLEXITY	97166	HCPCS	434	RC		both	269	228.65	Medicaid Idaho	Default	Fee Schedule	123.74				96.01	260.93
OT EVALUATION MODERATE COMPLEXITY	97166	HCPCS	434	RC		both	269	228.65	Medicare A ID JF	Default	Other	104.91		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	96.01	260.93
OT EVALUATION MODERATE COMPLEXITY	97166	HCPCS	434	RC		both	269	228.65	Medicare B ID JF	Default	Fee Schedule	96.01		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		96.01	260.93
OT EVALUATION MODERATE COMPLEXITY	97166	HCPCS	434	RC		both	269	228.65	Regence Group Administrators	Default	Fee Schedule	260.93				96.01	260.93
OT EVALUATION MODERATE COMPLEXITY	97166	HCPCS	434	RC		both	269	228.65	SelectHealth	Default	Percent of Total Billed Charges	255.55				96.01	260.93
OT EVALUATION HIGH COMPLEXITY	97167	HCPCS	434	RC	GO	both	302	256.7	Blue Cross of ID	Default	Percent of Total Billed Charges	292.94				96.01	292.94
OT EVALUATION HIGH COMPLEXITY	97167	HCPCS	434	RC	GO	both	302	256.7	Medicaid Idaho	Default	Fee Schedule	138.92				96.01	292.94
OT EVALUATION HIGH COMPLEXITY	97167	HCPCS	434	RC	GO	both	302	256.7	Medicare A ID JF	Default	Other	117.78		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	96.01	292.94
OT EVALUATION HIGH COMPLEXITY	97167	HCPCS	434	RC	GO	both	302	256.7	Medicare B ID JF	Default	Fee Schedule	96.01		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		96.01	292.94
OT EVALUATION HIGH COMPLEXITY	97167	HCPCS	434	RC	GO	both	302	256.7	Regence Group Administrators	Default	Fee Schedule	292.94				96.01	292.94
OT EVALUATION HIGH COMPLEXITY	97167	HCPCS	434	RC	GO	both	302	256.7	SelectHealth	Default	Percent of Total Billed Charges	286.9				96.01	292.94
OT EVALUATION HIGH COMPLEXITY	97167	HCPCS	434	RC		both	302	256.7	Blue Cross of ID	Default	Percent of Total Billed Charges	292.94				96.01	292.94
OT EVALUATION HIGH COMPLEXITY	97167	HCPCS	434	RC		both	302	256.7	Medicaid Idaho	Default	Fee Schedule	138.92				96.01	292.94
OT EVALUATION HIGH COMPLEXITY	97167	HCPCS	434	RC		both	302	256.7	Medicare A ID JF	Default	Other	117.78		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	96.01	292.94
OT EVALUATION HIGH COMPLEXITY	97167	HCPCS	434	RC		both	302	256.7	Medicare B ID JF	Default	Fee Schedule	96.01		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		96.01	292.94
OT EVALUATION HIGH COMPLEXITY	97167	HCPCS	434	RC		both	302	256.7	Regence Group Administrators	Default	Fee Schedule	292.94				96.01	292.94
OT EVALUATION HIGH COMPLEXITY	97167	HCPCS	434	RC		both	302	256.7	SelectHealth	Default	Percent of Total Billed Charges	286.9				96.01	292.94
OT RE-EVALUATION	97168	HCPCS	434	RC	GO	both	241.5	205.28	Blue Cross of ID	Default	Percent of Total Billed Charges	234.26				65.97	234.26
OT RE-EVALUATION	97168	HCPCS	434	RC	GO	both	241.5	205.28	Medicaid Idaho	Default	Fee Schedule	111.09				65.97	234.26
OT RE-EVALUATION	97168	HCPCS	434	RC	GO	both	241.5	205.28	Medicare A ID JF	Default	Other	94.19		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	65.97	234.26
OT RE-EVALUATION	97168	HCPCS	434	RC	GO	both	241.5	205.28	Medicare B ID JF	Default	Fee Schedule	65.97		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		65.97	234.26
OT RE-EVALUATION	97168	HCPCS	434	RC	GO	both	241.5	205.28	Regence Group Administrators	Default	Fee Schedule	234.26				65.97	234.26
OT RE-EVALUATION	97168	HCPCS	434	RC	GO	both	241.5	205.28	SelectHealth	Default	Percent of Total Billed Charges	229.42				65.97	234.26
OT RE-EVALUATION	97168	HCPCS	434	RC		both	241.5	205.28	Blue Cross of ID	Default	Percent of Total Billed Charges	234.26				65.97	234.26
OT RE-EVALUATION	97168	HCPCS	434	RC		both	241.5	205.28	Medicaid Idaho	Default	Fee Schedule	111.09				65.97	234.26
OT RE-EVALUATION	97168	HCPCS	434	RC		both	241.5	205.28	Medicare A ID JF	Default	Other	94.19		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	65.97	234.26
OT RE-EVALUATION	97168	HCPCS	434	RC		both	241.5	205.28	Medicare B ID JF	Default	Fee Schedule	65.97		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		65.97	234.26
OT RE-EVALUATION	97168	HCPCS	434	RC		both	241.5	205.28	Regence Group Administrators	Default	Fee Schedule	234.26				65.97	234.26
OT RE-EVALUATION	97168	HCPCS	434	RC		both	241.5	205.28	SelectHealth	Default	Percent of Total Billed Charges	229.42				65.97	234.26
OT THERAPEUTIC ACTIVITY DIRECT PT CONTAC	97530	HCPCS	430	RC	GO	both	125	106.25	Blue Cross of ID	Default	Percent of Total Billed Charges	121.25				33.67	121.25
OT THERAPEUTIC ACTIVITY DIRECT PT CONTAC	97530	HCPCS	430	RC	GO	both	125	106.25	Medicaid Idaho	Default	Fee Schedule	33.67				33.67	121.25
OT THERAPEUTIC ACTIVITY DIRECT PT CONTAC	97530	HCPCS	430	RC	GO	both	125	106.25	Medicare A ID JF	Default	Other	48.75		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	33.67	121.25
OT THERAPEUTIC ACTIVITY DIRECT PT CONTAC	97530	HCPCS	430	RC	GO	both	125	106.25	Medicare B ID JF	Default	Fee Schedule	34.45		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		33.67	121.25
OT THERAPEUTIC ACTIVITY DIRECT PT CONTAC	97530	HCPCS	430	RC	GO	both	125	106.25	Regence Group Administrators	Default	Fee Schedule	121.25				33.67	121.25
OT THERAPEUTIC ACTIVITY DIRECT PT CONTAC	97530	HCPCS	430	RC	GO	both	125	106.25	SelectHealth	Default	Percent of Total Billed Charges	118.75				33.67	121.25
OT THERAPEUTIC ACTIVITY DIRECT PT CONTAC	97530	HCPCS	430	RC		both	125	106.25	Blue Cross of ID	Default	Percent of Total Billed Charges	121.25				33.67	121.25
OT THERAPEUTIC ACTIVITY DIRECT PT CONTAC	97530	HCPCS	430	RC		both	125	106.25	Medicaid Idaho	Default	Fee Schedule	33.67				33.67	121.25
OT THERAPEUTIC ACTIVITY DIRECT PT CONTAC	97530	HCPCS	430	RC		both	125	106.25	Medicare A ID JF	Default	Other	48.75		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	33.67	121.25
OT THERAPEUTIC ACTIVITY DIRECT PT CONTAC	97530	HCPCS	430	RC		both	125	106.25	Medicare B ID JF	Default	Fee Schedule	34.45		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		33.67	121.25
OT THERAPEUTIC ACTIVITY DIRECT PT CONTAC	97530	HCPCS	430	RC		both	125	106.25	Regence Group Administrators	Default	Fee Schedule	121.25				33.67	121.25
OT THERAPEUTIC ACTIVITY DIRECT PT CONTAC	97530	HCPCS	430	RC		both	125	106.25	SelectHealth	Default	Percent of Total Billed Charges	118.75				33.67	121.25
OT SENSORY INTEGRATIVE TECHNIQUES	97533	HCPCS	430	RC	GO	both	83.5	70.98	Blue Cross of ID	Default	Percent of Total Billed Charges	81				32.57	81
OT SENSORY INTEGRATIVE TECHNIQUES	97533	HCPCS	430	RC	GO	both	83.5	70.98	Medicaid Idaho	Default	Fee Schedule	38.41				32.57	81
OT SENSORY INTEGRATIVE TECHNIQUES	97533	HCPCS	430	RC	GO	both	83.5	70.98	Medicare A ID JF	Default	Other	32.57		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	32.57	81
OT SENSORY INTEGRATIVE TECHNIQUES	97533	HCPCS	430	RC	GO	both	83.5	70.98	Medicare B ID JF	Default	Fee Schedule	57.84		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		32.57	81
OT SENSORY INTEGRATIVE TECHNIQUES	97533	HCPCS	430	RC	GO	both	83.5	70.98	Regence Group Administrators	Default	Fee Schedule	81				32.57	81
OT SENSORY INTEGRATIVE TECHNIQUES	97533	HCPCS	430	RC	GO	both	83.5	70.98	SelectHealth	Default	Percent of Total Billed Charges	79.32				32.57	81
OT SENSORY INTEGRATIVE TECHNIQUES	97533	HCPCS	430	RC		both	83.5	70.98	Blue Cross of ID	Default	Percent of Total Billed Charges	81				32.57	81
OT SENSORY INTEGRATIVE TECHNIQUES	97533	HCPCS	430	RC		both	83.5	70.98	Medicaid Idaho	Default	Fee Schedule	38.41				32.57	81
OT SENSORY INTEGRATIVE TECHNIQUES	97533	HCPCS	430	RC		both	83.5	70.98	Medicare A ID JF	Default	Other	32.57		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	32.57	81
OT SENSORY INTEGRATIVE TECHNIQUES	97533	HCPCS	430	RC		both	83.5	70.98	Medicare B ID JF	Default	Fee Schedule	57.84		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		32.57	81
OT SENSORY INTEGRATIVE TECHNIQUES	97533	HCPCS	430	RC		both	83.5	70.98	Regence Group Administrators	Default	Fee Schedule	81				32.57	81
OT SENSORY INTEGRATIVE TECHNIQUES	97533	HCPCS	430	RC		both	83.5	70.98	SelectHealth	Default	Percent of Total Billed Charges	79.32				32.57	81
OT ADLS/ SELF CARE	97535	HCPCS	430	RC	GO	both	125	106.25	Blue Cross of ID	Default	Percent of Total Billed Charges	121.25				30.85	121.25
OT ADLS/ SELF CARE	97535	HCPCS	430	RC	GO	both	125	106.25	Medicaid Idaho	Default	Fee Schedule	57.5				30.85	121.25
OT ADLS/ SELF CARE	97535	HCPCS	430	RC	GO	both	125	106.25	Medicare A ID JF	Default	Other	48.75		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	30.85	121.25
OT ADLS/ SELF CARE	97535	HCPCS	430	RC	GO	both	125	106.25	Medicare B ID JF	Default	Fee Schedule	30.85		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		30.85	121.25
OT ADLS/ SELF CARE	97535	HCPCS	430	RC	GO	both	125	106.25	Regence Group Administrators	Default	Fee Schedule	121.25				30.85	121.25
OT ADLS/ SELF CARE	97535	HCPCS	430	RC	GO	both	125	106.25	SelectHealth	Default	Percent of Total Billed Charges	118.75				30.85	121.25
OT ADLS/ SELF CARE	97535	HCPCS	430	RC		both	125	106.25	Blue Cross of ID	Default	Percent of Total Billed Charges	121.25				30.85	121.25
OT ADLS/ SELF CARE	97535	HCPCS	430	RC		both	125	106.25	Medicaid Idaho	Default	Fee Schedule	57.5				30.85	121.25
OT ADLS/ SELF CARE	97535	HCPCS	430	RC		both	125	106.25	Medicare A ID JF	Default	Other	48.75		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	30.85	121.25
OT ADLS/ SELF CARE	97535	HCPCS	430	RC		both	125	106.25	Medicare B ID JF	Default	Fee Schedule	30.85		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		30.85	121.25
OT ADLS/ SELF CARE	97535	HCPCS	430	RC		both	125	106.25	Regence Group Administrators	Default	Fee Schedule	121.25				30.85	121.25
OT ADLS/ SELF CARE	97535	HCPCS	430	RC		both	125	106.25	SelectHealth	Default	Percent of Total Billed Charges	118.75				30.85	121.25
OT COMMUNITY/WORK REINTEGRATION 15 MIN	97537	HCPCS	430	RC	GO	both	97	82.45	Blue Cross of ID	Default	Percent of Total Billed Charges	94.09				30.03	94.09
OT COMMUNITY/WORK REINTEGRATION 15 MIN	97537	HCPCS	430	RC	GO	both	97	82.45	Medicaid Idaho	Default	Fee Schedule	44.62				30.03	94.09
OT COMMUNITY/WORK REINTEGRATION 15 MIN	97537	HCPCS	430	RC	GO	both	97	82.45	Medicare A ID JF	Default	Other	37.83		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	30.03	94.09
OT COMMUNITY/WORK REINTEGRATION 15 MIN	97537	HCPCS	430	RC	GO	both	97	82.45	Medicare B ID JF	Default	Fee Schedule	30.03		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		30.03	94.09
OT COMMUNITY/WORK REINTEGRATION 15 MIN	97537	HCPCS	430	RC	GO	both	97	82.45	Regence Group Administrators	Default	Fee Schedule	94.09				30.03	94.09
OT COMMUNITY/WORK REINTEGRATION 15 MIN	97537	HCPCS	430	RC	GO	both	97	82.45	SelectHealth	Default	Percent of Total Billed Charges	92.15				30.03	94.09
OT COMMUNITY/WORK REINTEGRATION 15 MIN	97537	HCPCS	430	RC		both	97	82.45	Blue Cross of ID	Default	Percent of Total Billed Charges	94.09				30.03	94.09
OT COMMUNITY/WORK REINTEGRATION 15 MIN	97537	HCPCS	430	RC		both	97	82.45	Medicaid Idaho	Default	Fee Schedule	44.62				30.03	94.09
OT COMMUNITY/WORK REINTEGRATION 15 MIN	97537	HCPCS	430	RC		both	97	82.45	Medicare A ID JF	Default	Other	37.83		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	30.03	94.09
OT COMMUNITY/WORK REINTEGRATION 15 MIN	97537	HCPCS	430	RC		both	97	82.45	Medicare B ID JF	Default	Fee Schedule	30.03		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		30.03	94.09
OT COMMUNITY/WORK REINTEGRATION 15 MIN	97537	HCPCS	430	RC		both	97	82.45	Regence Group Administrators	Default	Fee Schedule	94.09				30.03	94.09
OT COMMUNITY/WORK REINTEGRATION 15 MIN	97537	HCPCS	430	RC		both	97	82.45	SelectHealth	Default	Percent of Total Billed Charges	92.15				30.03	94.09
OT WHEELCHAIR MGMT 15 MIN	97542	HCPCS	430	RC	GO	both	98.5	83.73	Blue Cross of ID	Default	Percent of Total Billed Charges	95.54				30.03	95.54
OT WHEELCHAIR MGMT 15 MIN	97542	HCPCS	430	RC	GO	both	98.5	83.73	Medicaid Idaho	Default	Fee Schedule	45.31				30.03	95.54
OT WHEELCHAIR MGMT 15 MIN	97542	HCPCS	430	RC	GO	both	98.5	83.73	Medicare A ID JF	Default	Other	38.42		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	30.03	95.54
OT WHEELCHAIR MGMT 15 MIN	97542	HCPCS	430	RC	GO	both	98.5	83.73	Medicare B ID JF	Default	Fee Schedule	30.03		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		30.03	95.54
OT WHEELCHAIR MGMT 15 MIN	97542	HCPCS	430	RC	GO	both	98.5	83.73	Regence Group Administrators	Default	Fee Schedule	95.54				30.03	95.54
OT WHEELCHAIR MGMT 15 MIN	97542	HCPCS	430	RC	GO	both	98.5	83.73	SelectHealth	Default	Percent of Total Billed Charges	93.58				30.03	95.54
OT WHEELCHAIR MGMT 15 MIN	97542	HCPCS	430	RC		both	98.5	83.73	Blue Cross of ID	Default	Percent of Total Billed Charges	95.54				30.03	95.54
OT WHEELCHAIR MGMT 15 MIN	97542	HCPCS	430	RC		both	98.5	83.73	Medicaid Idaho	Default	Fee Schedule	45.31				30.03	95.54
OT WHEELCHAIR MGMT 15 MIN	97542	HCPCS	430	RC		both	98.5	83.73	Medicare A ID JF	Default	Other	38.42		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	30.03	95.54
OT WHEELCHAIR MGMT 15 MIN	97542	HCPCS	430	RC		both	98.5	83.73	Medicare B ID JF	Default	Fee Schedule	30.03		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		30.03	95.54
OT WHEELCHAIR MGMT 15 MIN	97542	HCPCS	430	RC		both	98.5	83.73	Regence Group Administrators	Default	Fee Schedule	95.54				30.03	95.54
OT WHEELCHAIR MGMT 15 MIN	97542	HCPCS	430	RC		both	98.5	83.73	SelectHealth	Default	Percent of Total Billed Charges	93.58				30.03	95.54
OT PHYSICAL PERFORMANCE TEST	97750	HCPCS	430	RC	GO	both	152.5	129.63	Blue Cross of ID	Default	Percent of Total Billed Charges	147.92				32.06	147.92
OT PHYSICAL PERFORMANCE TEST	97750	HCPCS	430	RC	GO	both	152.5	129.63	Medicaid Idaho	Default	Fee Schedule	70.15				32.06	147.92
OT PHYSICAL PERFORMANCE TEST	97750	HCPCS	430	RC	GO	both	152.5	129.63	Medicare A ID JF	Default	Other	59.48		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	32.06	147.92
OT PHYSICAL PERFORMANCE TEST	97750	HCPCS	430	RC	GO	both	152.5	129.63	Medicare B ID JF	Default	Fee Schedule	32.06		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		32.06	147.92
OT PHYSICAL PERFORMANCE TEST	97750	HCPCS	430	RC	GO	both	152.5	129.63	Regence Group Administrators	Default	Fee Schedule	147.92				32.06	147.92
OT PHYSICAL PERFORMANCE TEST	97750	HCPCS	430	RC	GO	both	152.5	129.63	SelectHealth	Default	Percent of Total Billed Charges	144.88				32.06	147.92
OT PHYSICAL PERFORMANCE TEST	97750	HCPCS	430	RC		both	152.5	129.63	Blue Cross of ID	Default	Percent of Total Billed Charges	147.92				32.06	147.92
OT PHYSICAL PERFORMANCE TEST	97750	HCPCS	430	RC		both	152.5	129.63	Medicaid Idaho	Default	Fee Schedule	70.15				32.06	147.92
OT PHYSICAL PERFORMANCE TEST	97750	HCPCS	430	RC		both	152.5	129.63	Medicare A ID JF	Default	Other	59.48		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	32.06	147.92
OT PHYSICAL PERFORMANCE TEST	97750	HCPCS	430	RC		both	152.5	129.63	Medicare B ID JF	Default	Fee Schedule	32.06		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		32.06	147.92
OT PHYSICAL PERFORMANCE TEST	97750	HCPCS	430	RC		both	152.5	129.63	Regence Group Administrators	Default	Fee Schedule	147.92				32.06	147.92
OT PHYSICAL PERFORMANCE TEST	97750	HCPCS	430	RC		both	152.5	129.63	SelectHealth	Default	Percent of Total Billed Charges	144.88				32.06	147.92
OT ASSISTIVE TECHNOLOGY ASSESS	97755	HCPCS	430	RC	GO	both	62.5	53.13	Blue Cross of ID	Default	Percent of Total Billed Charges	60.62				24.38	60.62
OT ASSISTIVE TECHNOLOGY ASSESS	97755	HCPCS	430	RC	GO	both	62.5	53.13	Medicaid Idaho	Default	Fee Schedule	28.75				24.38	60.62
OT ASSISTIVE TECHNOLOGY ASSESS	97755	HCPCS	430	RC	GO	both	62.5	53.13	Medicare A ID JF	Default	Other	24.38		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	24.38	60.62
OT ASSISTIVE TECHNOLOGY ASSESS	97755	HCPCS	430	RC	GO	both	62.5	53.13	Medicare B ID JF	Default	Fee Schedule	36.36		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		24.38	60.62
OT ASSISTIVE TECHNOLOGY ASSESS	97755	HCPCS	430	RC	GO	both	62.5	53.13	Regence Group Administrators	Default	Fee Schedule	60.62				24.38	60.62
OT ASSISTIVE TECHNOLOGY ASSESS	97755	HCPCS	430	RC	GO	both	62.5	53.13	SelectHealth	Default	Percent of Total Billed Charges	59.38				24.38	60.62
OT ASSISTIVE TECHNOLOGY ASSESS	97755	HCPCS	430	RC		both	62.5	53.13	Blue Cross of ID	Default	Percent of Total Billed Charges	60.62				24.38	60.62
OT ASSISTIVE TECHNOLOGY ASSESS	97755	HCPCS	430	RC		both	62.5	53.13	Medicaid Idaho	Default	Fee Schedule	28.75				24.38	60.62
OT ASSISTIVE TECHNOLOGY ASSESS	97755	HCPCS	430	RC		both	62.5	53.13	Medicare A ID JF	Default	Other	24.38		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	24.38	60.62
OT ASSISTIVE TECHNOLOGY ASSESS	97755	HCPCS	430	RC		both	62.5	53.13	Medicare B ID JF	Default	Fee Schedule	36.36		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		24.38	60.62
OT ASSISTIVE TECHNOLOGY ASSESS	97755	HCPCS	430	RC		both	62.5	53.13	Regence Group Administrators	Default	Fee Schedule	60.62				24.38	60.62
OT ASSISTIVE TECHNOLOGY ASSESS	97755	HCPCS	430	RC		both	62.5	53.13	SelectHealth	Default	Percent of Total Billed Charges	59.38				24.38	60.62
OT BRACE FITTING	97760	HCPCS	430	RC	GO	both	112	95.2	Blue Cross of ID	Default	Percent of Total Billed Charges	108.64				40.2	108.64
OT BRACE FITTING	97760	HCPCS	430	RC	GO	both	112	95.2	Medicaid Idaho	Default	Fee Schedule	40.2				40.2	108.64
OT BRACE FITTING	97760	HCPCS	430	RC	GO	both	112	95.2	Medicare A ID JF	Default	Other	43.68		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	40.2	108.64
OT BRACE FITTING	97760	HCPCS	430	RC	GO	both	112	95.2	Medicare B ID JF	Default	Fee Schedule	44.6		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		40.2	108.64
OT BRACE FITTING	97760	HCPCS	430	RC	GO	both	112	95.2	Regence Group Administrators	Default	Fee Schedule	108.64				40.2	108.64
OT BRACE FITTING	97760	HCPCS	430	RC	GO	both	112	95.2	SelectHealth	Default	Percent of Total Billed Charges	106.4				40.2	108.64
OT BRACE FITTING	97760	HCPCS	430	RC		both	112	95.2	Blue Cross of ID	Default	Percent of Total Billed Charges	108.64				40.2	108.64
OT BRACE FITTING	97760	HCPCS	430	RC		both	112	95.2	Medicaid Idaho	Default	Fee Schedule	40.2				40.2	108.64
OT BRACE FITTING	97760	HCPCS	430	RC		both	112	95.2	Medicare A ID JF	Default	Other	43.68		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	40.2	108.64
OT BRACE FITTING	97760	HCPCS	430	RC		both	112	95.2	Medicare B ID JF	Default	Fee Schedule	44.6		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		40.2	108.64
OT BRACE FITTING	97760	HCPCS	430	RC		both	112	95.2	Regence Group Administrators	Default	Fee Schedule	108.64				40.2	108.64
OT BRACE FITTING	97760	HCPCS	430	RC		both	112	95.2	SelectHealth	Default	Percent of Total Billed Charges	106.4				40.2	108.64
OT MEDICAL TEAM CONFERENCE 30 MIN	99366	HCPCS	430	RC	GO	both	78	66.3	Blue Cross of ID	Default	Percent of Total Billed Charges	75.66				30.42	75.66
OT MEDICAL TEAM CONFERENCE 30 MIN	99366	HCPCS	430	RC	GO	both	78	66.3	Medicaid Idaho	Default	Fee Schedule	35.88				30.42	75.66
OT MEDICAL TEAM CONFERENCE 30 MIN	99366	HCPCS	430	RC	GO	both	78	66.3	Medicare A ID JF	Default	Other	30.42		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	30.42	75.66
OT MEDICAL TEAM CONFERENCE 30 MIN	99366	HCPCS	430	RC	GO	both	78	66.3	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		30.42	75.66
OT MEDICAL TEAM CONFERENCE 30 MIN	99366	HCPCS	430	RC	GO	both	78	66.3	Regence Group Administrators	Default	Fee Schedule	75.66				30.42	75.66
OT MEDICAL TEAM CONFERENCE 30 MIN	99366	HCPCS	430	RC	GO	both	78	66.3	SelectHealth	Default	Percent of Total Billed Charges	74.1				30.42	75.66
OT MEDICAL TEAM CONFERENCE 30 MIN	99366	HCPCS	430	RC		both	45	38.25	Blue Cross of ID	Default	Percent of Total Billed Charges	43.65				17.55	43.65
OT MEDICAL TEAM CONFERENCE 30 MIN	99366	HCPCS	430	RC		both	45	38.25	Medicaid Idaho	Default	Fee Schedule	20.7				17.55	43.65
OT MEDICAL TEAM CONFERENCE 30 MIN	99366	HCPCS	430	RC		both	45	38.25	Medicare A ID JF	Default	Other	17.55		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	17.55	43.65
OT MEDICAL TEAM CONFERENCE 30 MIN	99366	HCPCS	430	RC		both	45	38.25	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		17.55	43.65
OT MEDICAL TEAM CONFERENCE 30 MIN	99366	HCPCS	430	RC		both	45	38.25	Regence Group Administrators	Default	Fee Schedule	43.65				17.55	43.65
OT MEDICAL TEAM CONFERENCE 30 MIN	99366	HCPCS	430	RC		both	45	38.25	SelectHealth	Default	Percent of Total Billed Charges	42.75				17.55	43.65
SEMI-PRIVATE 2	100	RC				inpatient	1583	1345.55	Blue Cross of ID	Default	Percent of Total Billed Charges	1519.68				918.14	3495
SEMI-PRIVATE 2	100	RC				inpatient	1583	1345.55	Medicaid Idaho	Default	Percent of Total Billed Charges	918.14				918.14	3495
SEMI-PRIVATE 2	100	RC				inpatient	1583	1345.55	Medicare A ID JF	Default	Per Diem	3495				918.14	3495
SEMI-PRIVATE 2	100	RC				inpatient	1583	1345.55	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		918.14	3495
SEMI-PRIVATE 2	100	RC				inpatient	1583	1345.55	Regence Group Administrators	Default	Percent of Total Billed Charges	1535.51				918.14	3495
SEMI-PRIVATE 2	100	RC				inpatient	1583	1345.55	SelectHealth	Default	Percent of Total Billed Charges	1503.85				918.14	3495
EXC BE LESION TAL EA ADD	11401	HCPCS	761	RC		both	120.5	102.43	Blue Cross of ID	Default	Percent of Total Billed Charges	116.88				47	120.5
EXC BE LESION TAL EA ADD	11401	HCPCS	761	RC		both	120.5	102.43	Medicaid Idaho	Default	Fee Schedule	55.43				47	120.5
EXC BE LESION TAL EA ADD	11401	HCPCS	761	RC		both	120.5	102.43	Medicare A ID JF	Default	Other	47		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	47	120.5
EXC BE LESION TAL EA ADD	11401	HCPCS	761	RC		both	120.5	102.43	Medicare B ID JF	Default	Fee Schedule	120.5		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		47	120.5
EXC BE LESION TAL EA ADD	11401	HCPCS	761	RC		both	120.5	102.43	Regence Group Administrators	Default	Fee Schedule	116.88				47	120.5
EXC BE LESION TAL EA ADD	11401	HCPCS	761	RC		both	120.5	102.43	SelectHealth	Default	Percent of Total Billed Charges	114.48				47	120.5
EXC BENIGN LESION SNHFG EA ADD	11422	HCPCS	761	RC		both	120.5	102.43	Blue Cross of ID	Default	Percent of Total Billed Charges	116.88				47	120.5
EXC BENIGN LESION SNHFG EA ADD	11422	HCPCS	761	RC		both	120.5	102.43	Medicaid Idaho	Default	Fee Schedule	55.43				47	120.5
EXC BENIGN LESION SNHFG EA ADD	11422	HCPCS	761	RC		both	120.5	102.43	Medicare A ID JF	Default	Other	47		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	47	120.5
EXC BENIGN LESION SNHFG EA ADD	11422	HCPCS	761	RC		both	120.5	102.43	Medicare B ID JF	Default	Fee Schedule	120.5		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		47	120.5
EXC BENIGN LESION SNHFG EA ADD	11422	HCPCS	761	RC		both	120.5	102.43	Regence Group Administrators	Default	Fee Schedule	116.88				47	120.5
EXC BENIGN LESION SNHFG EA ADD	11422	HCPCS	761	RC		both	120.5	102.43	SelectHealth	Default	Percent of Total Billed Charges	114.48				47	120.5
"LAYER CLOSE S,A,T,E EA ADD"	12031	HCPCS	761	RC		both	120.5	102.43	Blue Cross of ID	Default	Percent of Total Billed Charges	116.88				47	120.5
"LAYER CLOSE S,A,T,E EA ADD"	12031	HCPCS	761	RC		both	120.5	102.43	Medicaid Idaho	Default	Fee Schedule	55.43				47	120.5
"LAYER CLOSE S,A,T,E EA ADD"	12031	HCPCS	761	RC		both	120.5	102.43	Medicare A ID JF	Default	Other	47		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	47	120.5
"LAYER CLOSE S,A,T,E EA ADD"	12031	HCPCS	761	RC		both	120.5	102.43	Medicare B ID JF	Default	Fee Schedule	120.5		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		47	120.5
"LAYER CLOSE S,A,T,E EA ADD"	12031	HCPCS	761	RC		both	120.5	102.43	Regence Group Administrators	Default	Fee Schedule	116.88				47	120.5
"LAYER CLOSE S,A,T,E EA ADD"	12031	HCPCS	761	RC		both	120.5	102.43	SelectHealth	Default	Percent of Total Billed Charges	114.48				47	120.5
NERVE BLOCK/INJ	1991	HCPCS	761	RC		both	190.5	161.93	Blue Cross of ID	Default	Percent of Total Billed Charges	184.78				1.98	184.78
NERVE BLOCK/INJ	1991	HCPCS	761	RC		both	190.5	161.93	Medicaid Idaho	Default	Fee Schedule	87.63				1.98	184.78
NERVE BLOCK/INJ	1991	HCPCS	761	RC		both	190.5	161.93	Medicare A ID JF	Default	Other	74.3		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	1.98	184.78
NERVE BLOCK/INJ	1991	HCPCS	761	RC		both	190.5	161.93	Medicare B ID JF	Default	Fee Schedule	1.98		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		1.98	184.78
NERVE BLOCK/INJ	1991	HCPCS	761	RC		both	190.5	161.93	Regence Group Administrators	Default	Fee Schedule	184.78				1.98	184.78
NERVE BLOCK/INJ	1991	HCPCS	761	RC		both	190.5	161.93	SelectHealth	Default	Percent of Total Billed Charges	180.98				1.98	184.78
NERVE BLOCK	1992	HCPCS	761	RC		both	730.5	620.93	Blue Cross of ID	Default	Percent of Total Billed Charges	708.58				1.98	708.58
NERVE BLOCK	1992	HCPCS	761	RC		both	730.5	620.93	Medicaid Idaho	Default	Fee Schedule	336.03				1.98	708.58
NERVE BLOCK	1992	HCPCS	761	RC		both	730.5	620.93	Medicare A ID JF	Default	Other	284.9		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	1.98	708.58
NERVE BLOCK	1992	HCPCS	761	RC		both	730.5	620.93	Medicare B ID JF	Default	Fee Schedule	1.98		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		1.98	708.58
NERVE BLOCK	1992	HCPCS	761	RC		both	730.5	620.93	Regence Group Administrators	Default	Fee Schedule	708.58				1.98	708.58
NERVE BLOCK	1992	HCPCS	761	RC		both	730.5	620.93	SelectHealth	Default	Percent of Total Billed Charges	693.98				1.98	708.58
BIVALENT BOOSTER ADMIN	0031A	HCPCS	771	RC		both	58	49.3	Blue Cross of ID	Default	Percent of Total Billed Charges	56.26				22.62	56.26
BIVALENT BOOSTER ADMIN	0031A	HCPCS	771	RC		both	58	49.3	Medicaid Idaho	Default	Fee Schedule	26.68				22.62	56.26
BIVALENT BOOSTER ADMIN	0031A	HCPCS	771	RC		both	58	49.3	Medicare A ID JF	Default	Other	22.62		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	22.62	56.26
BIVALENT BOOSTER ADMIN	0031A	HCPCS	771	RC		both	58	49.3	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		22.62	56.26
BIVALENT BOOSTER ADMIN	0031A	HCPCS	771	RC		both	58	49.3	Regence Group Administrators	Default	Fee Schedule	56.26				22.62	56.26
BIVALENT BOOSTER ADMIN	0031A	HCPCS	771	RC		both	58	49.3	SelectHealth	Default	Percent of Total Billed Charges	55.1				22.62	56.26
TSE PRIORITY 1	G0390	HCPCS	684	RC		both	1478.5	1256.73	Blue Cross of ID	Default	Percent of Total Billed Charges	1434.14				576.62	1434.14
TSE PRIORITY 1	G0390	HCPCS	684	RC		both	1478.5	1256.73	Medicaid Idaho	Default	Fee Schedule	680.11				576.62	1434.14
TSE PRIORITY 1	G0390	HCPCS	684	RC		both	1478.5	1256.73	Medicare A ID JF	Default	Other	576.62		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	576.62	1434.14
TSE PRIORITY 1	G0390	HCPCS	684	RC		both	1478.5	1256.73	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		576.62	1434.14
TSE PRIORITY 1	G0390	HCPCS	684	RC		both	1478.5	1256.73	Regence Group Administrators	Default	Fee Schedule	1434.14				576.62	1434.14
TSE PRIORITY 1	G0390	HCPCS	684	RC		both	1478.5	1256.73	SelectHealth	Default	Percent of Total Billed Charges	1404.58				576.62	1434.14
TSE PRIORITY 2	G0390	HCPCS	684	RC		both	1301	1105.85	Blue Cross of ID	Default	Percent of Total Billed Charges	1261.97				507.39	1261.97
TSE PRIORITY 2	G0390	HCPCS	684	RC		both	1301	1105.85	Medicaid Idaho	Default	Fee Schedule	598.46				507.39	1261.97
TSE PRIORITY 2	G0390	HCPCS	684	RC		both	1301	1105.85	Medicare A ID JF	Default	Other	507.39		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	507.39	1261.97
TSE PRIORITY 2	G0390	HCPCS	684	RC		both	1301	1105.85	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		507.39	1261.97
TSE PRIORITY 2	G0390	HCPCS	684	RC		both	1301	1105.85	Regence Group Administrators	Default	Fee Schedule	1261.97				507.39	1261.97
TSE PRIORITY 2	G0390	HCPCS	684	RC		both	1301	1105.85	SelectHealth	Default	Percent of Total Billed Charges	1235.95				507.39	1261.97
TSE PRIORITY 3	G0390	HCPCS	684	RC		both	1133	963.05	Blue Cross of ID	Default	Percent of Total Billed Charges	1099.01				441.87	1099.01
TSE PRIORITY 3	G0390	HCPCS	684	RC		both	1133	963.05	Medicaid Idaho	Default	Fee Schedule	521.18				441.87	1099.01
TSE PRIORITY 3	G0390	HCPCS	684	RC		both	1133	963.05	Medicare A ID JF	Default	Other	441.87		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	441.87	1099.01
TSE PRIORITY 3	G0390	HCPCS	684	RC		both	1133	963.05	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		441.87	1099.01
TSE PRIORITY 3	G0390	HCPCS	684	RC		both	1133	963.05	Regence Group Administrators	Default	Fee Schedule	1099.01				441.87	1099.01
TSE PRIORITY 3	G0390	HCPCS	684	RC		both	1133	963.05	SelectHealth	Default	Percent of Total Billed Charges	1076.35				441.87	1099.01
2X2 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	Blue Cross of ID	Default	Percent of Total Billed Charges	522.83				210.21	522.83
2X2 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	Medicaid Idaho	Default	Fee Schedule	247.94				210.21	522.83
2X2 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	Medicare A ID JF	Default	Other	210.21		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	210.21	522.83
2X2 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		210.21	522.83
2X2 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	Regence Group Administrators	Default	Fee Schedule	522.83				210.21	522.83
2X2 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	SelectHealth	Default	Percent of Total Billed Charges	512.05				210.21	522.83
FINE NEEDLE	10021	HCPCS	761	RC		both	294.5	250.33	Blue Cross of ID	Default	Percent of Total Billed Charges	285.66				92.96	285.66
FINE NEEDLE	10021	HCPCS	761	RC		both	294.5	250.33	Medicaid Idaho	Default	Fee Schedule	135.47				92.96	285.66
FINE NEEDLE	10021	HCPCS	761	RC		both	294.5	250.33	Medicare A ID JF	Default	Other	114.86		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	92.96	285.66
FINE NEEDLE	10021	HCPCS	761	RC		both	294.5	250.33	Medicare B ID JF	Default	Fee Schedule	92.96		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		92.96	285.66
FINE NEEDLE	10021	HCPCS	761	RC		both	294.5	250.33	Regence Group Administrators	Default	Fee Schedule	285.66				92.96	285.66
FINE NEEDLE	10021	HCPCS	761	RC		both	294.5	250.33	SelectHealth	Default	Percent of Total Billed Charges	279.78				92.96	285.66
FINE NEEDLE ASPIRATION; W/IMAGE GUIDANCE	10022	HCPCS	761	RC		both	337.5	286.88	Blue Cross of ID	Default	Percent of Total Billed Charges	327.38				131.63	327.38
FINE NEEDLE ASPIRATION; W/IMAGE GUIDANCE	10022	HCPCS	761	RC		both	337.5	286.88	Medicaid Idaho	Default	Fee Schedule	155.25				131.63	327.38
FINE NEEDLE ASPIRATION; W/IMAGE GUIDANCE	10022	HCPCS	761	RC		both	337.5	286.88	Medicare A ID JF	Default	Other	131.63		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	131.63	327.38
FINE NEEDLE ASPIRATION; W/IMAGE GUIDANCE	10022	HCPCS	761	RC		both	337.5	286.88	Medicare B ID JF	Default	Fee Schedule	132.54		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		131.63	327.38
FINE NEEDLE ASPIRATION; W/IMAGE GUIDANCE	10022	HCPCS	761	RC		both	337.5	286.88	Regence Group Administrators	Default	Fee Schedule	327.38				131.63	327.38
FINE NEEDLE ASPIRATION; W/IMAGE GUIDANCE	10022	HCPCS	761	RC		both	337.5	286.88	SelectHealth	Default	Percent of Total Billed Charges	320.62				131.63	327.38
I&D OF ABSCESS	10060	HCPCS	761	RC		both	392.5	333.63	Blue Cross of ID	Default	Percent of Total Billed Charges	380.72				117.56	380.72
I&D OF ABSCESS	10060	HCPCS	761	RC		both	392.5	333.63	Medicaid Idaho	Default	Fee Schedule	180.55				117.56	380.72
I&D OF ABSCESS	10060	HCPCS	761	RC		both	392.5	333.63	Medicare A ID JF	Default	Other	153.08		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	117.56	380.72
I&D OF ABSCESS	10060	HCPCS	761	RC		both	392.5	333.63	Medicare B ID JF	Default	Fee Schedule	117.56		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		117.56	380.72
I&D OF ABSCESS	10060	HCPCS	761	RC		both	392.5	333.63	Regence Group Administrators	Default	Fee Schedule	380.72				117.56	380.72
I&D OF ABSCESS	10060	HCPCS	761	RC		both	392.5	333.63	SelectHealth	Default	Percent of Total Billed Charges	372.88				117.56	380.72
I&D ABSCESS COMPLICATED/MULTI	10061	HCPCS	761	RC		both	539.5	458.58	Blue Cross of ID	Default	Percent of Total Billed Charges	523.32				198.3	523.32
I&D ABSCESS COMPLICATED/MULTI	10061	HCPCS	761	RC		both	539.5	458.58	Medicaid Idaho	Default	Fee Schedule	248.17				198.3	523.32
I&D ABSCESS COMPLICATED/MULTI	10061	HCPCS	761	RC		both	539.5	458.58	Medicare A ID JF	Default	Other	210.41		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	198.3	523.32
I&D ABSCESS COMPLICATED/MULTI	10061	HCPCS	761	RC		both	539.5	458.58	Medicare B ID JF	Default	Fee Schedule	198.3		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		198.3	523.32
I&D ABSCESS COMPLICATED/MULTI	10061	HCPCS	761	RC		both	539.5	458.58	Regence Group Administrators	Default	Fee Schedule	523.32				198.3	523.32
I&D ABSCESS COMPLICATED/MULTI	10061	HCPCS	761	RC		both	539.5	458.58	SelectHealth	Default	Percent of Total Billed Charges	512.52				198.3	523.32
I&D FOREIGN BODY SUBCU TISS SIMPLE	12031	HCPCS	761	RC		both	448.5	381.23	Blue Cross of ID	Default	Percent of Total Billed Charges	435.04				174.92	435.04
I&D FOREIGN BODY SUBCU TISS SIMPLE	12031	HCPCS	761	RC		both	448.5	381.23	Medicaid Idaho	Default	Fee Schedule	206.31				174.92	435.04
I&D FOREIGN BODY SUBCU TISS SIMPLE	12031	HCPCS	761	RC		both	448.5	381.23	Medicare A ID JF	Default	Other	174.92		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	174.92	435.04
I&D FOREIGN BODY SUBCU TISS SIMPLE	12031	HCPCS	761	RC		both	448.5	381.23	Medicare B ID JF	Default	Fee Schedule	241.49		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		174.92	435.04
I&D FOREIGN BODY SUBCU TISS SIMPLE	12031	HCPCS	761	RC		both	448.5	381.23	Regence Group Administrators	Default	Fee Schedule	435.04				174.92	435.04
I&D FOREIGN BODY SUBCU TISS SIMPLE	12031	HCPCS	761	RC		both	448.5	381.23	SelectHealth	Default	Percent of Total Billed Charges	426.08				174.92	435.04
I&D HEMATOMA/SEROMA	10140	HCPCS	761	RC		both	1255	1066.75	Blue Cross of ID	Default	Percent of Total Billed Charges	1217.35				156.47	1217.35
I&D HEMATOMA/SEROMA	10140	HCPCS	761	RC		both	1255	1066.75	Medicaid Idaho	Default	Fee Schedule	577.3				156.47	1217.35
I&D HEMATOMA/SEROMA	10140	HCPCS	761	RC		both	1255	1066.75	Medicare A ID JF	Default	Other	489.45		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	156.47	1217.35
I&D HEMATOMA/SEROMA	10140	HCPCS	761	RC		both	1255	1066.75	Medicare B ID JF	Default	Fee Schedule	156.47		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		156.47	1217.35
I&D HEMATOMA/SEROMA	10140	HCPCS	761	RC		both	1255	1066.75	Regence Group Administrators	Default	Fee Schedule	1217.35				156.47	1217.35
I&D HEMATOMA/SEROMA	10140	HCPCS	761	RC		both	1255	1066.75	SelectHealth	Default	Percent of Total Billed Charges	1192.25				156.47	1217.35
APIRATION ABSCESS/HEMA/CYST/SKIN/SUBQ	10160	HCPCS	761	RC		both	360.5	306.43	Blue Cross of ID	Default	Percent of Total Billed Charges	349.68				119.63	349.68
APIRATION ABSCESS/HEMA/CYST/SKIN/SUBQ	10160	HCPCS	761	RC		both	360.5	306.43	Medicaid Idaho	Default	Fee Schedule	165.83				119.63	349.68
APIRATION ABSCESS/HEMA/CYST/SKIN/SUBQ	10160	HCPCS	761	RC		both	360.5	306.43	Medicare A ID JF	Default	Other	140.6		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	119.63	349.68
APIRATION ABSCESS/HEMA/CYST/SKIN/SUBQ	10160	HCPCS	761	RC		both	360.5	306.43	Medicare B ID JF	Default	Fee Schedule	119.63		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		119.63	349.68
APIRATION ABSCESS/HEMA/CYST/SKIN/SUBQ	10160	HCPCS	761	RC		both	360.5	306.43	Regence Group Administrators	Default	Fee Schedule	349.68				119.63	349.68
APIRATION ABSCESS/HEMA/CYST/SKIN/SUBQ	10160	HCPCS	761	RC		both	360.5	306.43	SelectHealth	Default	Percent of Total Billed Charges	342.48				119.63	349.68
I&D COMPLEX POST OP/INFECT	10180	HCPCS	761	RC		both	892.5	758.63	Blue Cross of ID	Default	Percent of Total Billed Charges	865.72				238.84	865.72
I&D COMPLEX POST OP/INFECT	10180	HCPCS	761	RC		both	892.5	758.63	Medicaid Idaho	Default	Fee Schedule	410.55				238.84	865.72
I&D COMPLEX POST OP/INFECT	10180	HCPCS	761	RC		both	892.5	758.63	Medicare A ID JF	Default	Other	348.08		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	238.84	865.72
I&D COMPLEX POST OP/INFECT	10180	HCPCS	761	RC		both	892.5	758.63	Medicare B ID JF	Default	Fee Schedule	238.84		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		238.84	865.72
I&D COMPLEX POST OP/INFECT	10180	HCPCS	761	RC		both	892.5	758.63	Regence Group Administrators	Default	Fee Schedule	865.72				238.84	865.72
I&D COMPLEX POST OP/INFECT	10180	HCPCS	761	RC		both	892.5	758.63	SelectHealth	Default	Percent of Total Billed Charges	847.88				238.84	865.72
"DEBRIDEMENT, SUB 1ST 20 SQ CM OR LESS"	11042	HCPCS	761	RC		both	303.5	257.98	Blue Cross of ID	Default	Percent of Total Billed Charges	294.4				118.37	294.4
"DEBRIDEMENT, SUB 1ST 20 SQ CM OR LESS"	11042	HCPCS	761	RC		both	303.5	257.98	Medicaid Idaho	Default	Fee Schedule	139.61				118.37	294.4
"DEBRIDEMENT, SUB 1ST 20 SQ CM OR LESS"	11042	HCPCS	761	RC		both	303.5	257.98	Medicare A ID JF	Default	Other	118.37		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	118.37	294.4
"DEBRIDEMENT, SUB 1ST 20 SQ CM OR LESS"	11042	HCPCS	761	RC		both	303.5	257.98	Medicare B ID JF	Default	Fee Schedule	119.04		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		118.37	294.4
"DEBRIDEMENT, SUB 1ST 20 SQ CM OR LESS"	11042	HCPCS	761	RC		both	303.5	257.98	Regence Group Administrators	Default	Fee Schedule	294.4				118.37	294.4
"DEBRIDEMENT, SUB 1ST 20 SQ CM OR LESS"	11042	HCPCS	761	RC		both	303.5	257.98	SelectHealth	Default	Percent of Total Billed Charges	288.32				118.37	294.4
"DEBRIDEMENT,  1ST 20 SQ CM OR LESS"	11043	HCPCS	761	RC		both	551.5	468.78	Blue Cross of ID	Default	Percent of Total Billed Charges	534.96				213.59	534.96
"DEBRIDEMENT,  1ST 20 SQ CM OR LESS"	11043	HCPCS	761	RC		both	551.5	468.78	Medicaid Idaho	Default	Fee Schedule	253.69				213.59	534.96
"DEBRIDEMENT,  1ST 20 SQ CM OR LESS"	11043	HCPCS	761	RC		both	551.5	468.78	Medicare A ID JF	Default	Other	215.09		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	213.59	534.96
"DEBRIDEMENT,  1ST 20 SQ CM OR LESS"	11043	HCPCS	761	RC		both	551.5	468.78	Medicare B ID JF	Default	Fee Schedule	213.59		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		213.59	534.96
"DEBRIDEMENT,  1ST 20 SQ CM OR LESS"	11043	HCPCS	761	RC		both	551.5	468.78	Regence Group Administrators	Default	Fee Schedule	534.96				213.59	534.96
"DEBRIDEMENT,  1ST 20 SQ CM OR LESS"	11043	HCPCS	761	RC		both	551.5	468.78	SelectHealth	Default	Percent of Total Billed Charges	523.92				213.59	534.96
"DEBRIDEMENT, BONE FIRST 20 SQ CM OR LESS"	11044	HCPCS	761	RC		both	1071	910.35	Blue Cross of ID	Default	Percent of Total Billed Charges	1038.87				285.34	1038.87
"DEBRIDEMENT, BONE FIRST 20 SQ CM OR LESS"	11044	HCPCS	761	RC		both	1071	910.35	Medicaid Idaho	Default	Fee Schedule	492.66				285.34	1038.87
"DEBRIDEMENT, BONE FIRST 20 SQ CM OR LESS"	11044	HCPCS	761	RC		both	1071	910.35	Medicare A ID JF	Default	Other	417.69		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	285.34	1038.87
"DEBRIDEMENT, BONE FIRST 20 SQ CM OR LESS"	11044	HCPCS	761	RC		both	1071	910.35	Medicare B ID JF	Default	Fee Schedule	285.34		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		285.34	1038.87
"DEBRIDEMENT, BONE FIRST 20 SQ CM OR LESS"	11044	HCPCS	761	RC		both	1071	910.35	Regence Group Administrators	Default	Fee Schedule	1038.87				285.34	1038.87
"DEBRIDEMENT, BONE FIRST 20 SQ CM OR LESS"	11044	HCPCS	761	RC		both	1071	910.35	SelectHealth	Default	Percent of Total Billed Charges	1017.45				285.34	1038.87
"DEBRIDEMENT, SUB ADD 20 SQ CM OR LESS"	11045	HCPCS	761	RC		both	524	445.4	Blue Cross of ID	Default	Percent of Total Billed Charges	508.28				36.61	508.28
"DEBRIDEMENT, SUB ADD 20 SQ CM OR LESS"	11045	HCPCS	761	RC		both	524	445.4	Medicaid Idaho	Default	Fee Schedule	241.04				36.61	508.28
"DEBRIDEMENT, SUB ADD 20 SQ CM OR LESS"	11045	HCPCS	761	RC		both	524	445.4	Medicare A ID JF	Default	Other	204.36		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	36.61	508.28
"DEBRIDEMENT, SUB ADD 20 SQ CM OR LESS"	11045	HCPCS	761	RC		both	524	445.4	Medicare B ID JF	Default	Fee Schedule	36.61		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		36.61	508.28
"DEBRIDEMENT, SUB ADD 20 SQ CM OR LESS"	11045	HCPCS	761	RC		both	524	445.4	Regence Group Administrators	Default	Fee Schedule	508.28				36.61	508.28
"DEBRIDEMENT, SUB ADD 20 SQ CM OR LESS"	11045	HCPCS	761	RC		both	524	445.4	SelectHealth	Default	Percent of Total Billed Charges	497.8				36.61	508.28
"DEBRIDEMENT, MUSCLE ADD 20 SQ CM OR LESS"	11046	HCPCS	761	RC		both	606.5	515.53	Blue Cross of ID	Default	Percent of Total Billed Charges	588.3				66.52	588.3
"DEBRIDEMENT, MUSCLE ADD 20 SQ CM OR LESS"	11046	HCPCS	761	RC		both	606.5	515.53	Medicaid Idaho	Default	Fee Schedule	278.99				66.52	588.3
"DEBRIDEMENT, MUSCLE ADD 20 SQ CM OR LESS"	11046	HCPCS	761	RC		both	606.5	515.53	Medicare A ID JF	Default	Other	236.54		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	66.52	588.3
"DEBRIDEMENT, MUSCLE ADD 20 SQ CM OR LESS"	11046	HCPCS	761	RC		both	606.5	515.53	Medicare B ID JF	Default	Fee Schedule	66.52		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		66.52	588.3
"DEBRIDEMENT, MUSCLE ADD 20 SQ CM OR LESS"	11046	HCPCS	761	RC		both	606.5	515.53	Regence Group Administrators	Default	Fee Schedule	588.3				66.52	588.3
"DEBRIDEMENT, MUSCLE ADD 20 SQ CM OR LESS"	11046	HCPCS	761	RC		both	606.5	515.53	SelectHealth	Default	Percent of Total Billed Charges	576.18				66.52	588.3
"DEBRIDEMENT, BONE ADD 20 SQ CM OR LESS"	11047	HCPCS	761	RC		both	792	673.2	Blue Cross of ID	Default	Percent of Total Billed Charges	768.24				109.72	768.24
"DEBRIDEMENT, BONE ADD 20 SQ CM OR LESS"	11047	HCPCS	761	RC		both	792	673.2	Medicaid Idaho	Default	Fee Schedule	364.32				109.72	768.24
"DEBRIDEMENT, BONE ADD 20 SQ CM OR LESS"	11047	HCPCS	761	RC		both	792	673.2	Medicare A ID JF	Default	Other	308.88		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	109.72	768.24
"DEBRIDEMENT, BONE ADD 20 SQ CM OR LESS"	11047	HCPCS	761	RC		both	792	673.2	Medicare B ID JF	Default	Fee Schedule	109.72		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		109.72	768.24
"DEBRIDEMENT, BONE ADD 20 SQ CM OR LESS"	11047	HCPCS	761	RC		both	792	673.2	Regence Group Administrators	Default	Fee Schedule	768.24				109.72	768.24
"DEBRIDEMENT, BONE ADD 20 SQ CM OR LESS"	11047	HCPCS	761	RC		both	792	673.2	SelectHealth	Default	Percent of Total Billed Charges	752.4				109.72	768.24
BIOPSY OF SKIN	11100	HCPCS	761	RC		both	342.5	291.13	Blue Cross of ID	Default	Percent of Total Billed Charges	332.22				98.73	332.22
BIOPSY OF SKIN	11100	HCPCS	761	RC		both	342.5	291.13	Medicaid Idaho	Default	Fee Schedule	157.55				98.73	332.22
BIOPSY OF SKIN	11100	HCPCS	761	RC		both	342.5	291.13	Medicare A ID JF	Default	Other	133.58		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	98.73	332.22
BIOPSY OF SKIN	11100	HCPCS	761	RC		both	342.5	291.13	Medicare B ID JF	Default	Fee Schedule	98.73		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		98.73	332.22
BIOPSY OF SKIN	11100	HCPCS	761	RC		both	342.5	291.13	Regence Group Administrators	Default	Fee Schedule	332.22				98.73	332.22
BIOPSY OF SKIN	11100	HCPCS	761	RC		both	342.5	291.13	SelectHealth	Default	Percent of Total Billed Charges	325.38				98.73	332.22
BIOPSY OF SKIN EA/SEPERATE ADD	11101	HCPCS	761	RC		both	204	173.4	Blue Cross of ID	Default	Percent of Total Billed Charges	197.88				30.8	197.88
BIOPSY OF SKIN EA/SEPERATE ADD	11101	HCPCS	761	RC		both	204	173.4	Medicaid Idaho	Default	Fee Schedule	93.84				30.8	197.88
BIOPSY OF SKIN EA/SEPERATE ADD	11101	HCPCS	761	RC		both	204	173.4	Medicare A ID JF	Default	Other	79.56		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	30.8	197.88
BIOPSY OF SKIN EA/SEPERATE ADD	11101	HCPCS	761	RC		both	204	173.4	Medicare B ID JF	Default	Fee Schedule	30.8		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		30.8	197.88
BIOPSY OF SKIN EA/SEPERATE ADD	11101	HCPCS	761	RC		both	204	173.4	Regence Group Administrators	Default	Fee Schedule	197.88				30.8	197.88
BIOPSY OF SKIN EA/SEPERATE ADD	11101	HCPCS	761	RC		both	204	173.4	SelectHealth	Default	Percent of Total Billed Charges	193.8				30.8	197.88
EXC TONGUE LESION W CLOSURE	41113	HCPCS	761	RC		both	897.5	762.88	Blue Cross of ID	Default	Percent of Total Billed Charges	870.58				333.42	870.58
EXC TONGUE LESION W CLOSURE	41113	HCPCS	761	RC		both	897.5	762.88	Medicaid Idaho	Default	Fee Schedule	412.85				333.42	870.58
EXC TONGUE LESION W CLOSURE	41113	HCPCS	761	RC		both	897.5	762.88	Medicare A ID JF	Default	Other	350.03		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	333.42	870.58
EXC TONGUE LESION W CLOSURE	41113	HCPCS	761	RC		both	897.5	762.88	Medicare B ID JF	Default	Fee Schedule	333.42		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		333.42	870.58
EXC TONGUE LESION W CLOSURE	41113	HCPCS	761	RC		both	897.5	762.88	Regence Group Administrators	Default	Fee Schedule	870.58				333.42	870.58
EXC TONGUE LESION W CLOSURE	41113	HCPCS	761	RC		both	897.5	762.88	SelectHealth	Default	Percent of Total Billed Charges	852.62				333.42	870.58
REMOVAL SKIN TAGS<15	11200	HCPCS	761	RC		both	246	209.1	Blue Cross of ID	Default	Percent of Total Billed Charges	238.62				85.5	238.62
REMOVAL SKIN TAGS<15	11200	HCPCS	761	RC		both	246	209.1	Medicaid Idaho	Default	Fee Schedule	113.16				85.5	238.62
REMOVAL SKIN TAGS<15	11200	HCPCS	761	RC		both	246	209.1	Medicare A ID JF	Default	Other	95.94		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	85.5	238.62
REMOVAL SKIN TAGS<15	11200	HCPCS	761	RC		both	246	209.1	Medicare B ID JF	Default	Fee Schedule	85.5		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		85.5	238.62
REMOVAL SKIN TAGS<15	11200	HCPCS	761	RC		both	246	209.1	Regence Group Administrators	Default	Fee Schedule	238.62				85.5	238.62
REMOVAL SKIN TAGS<15	11200	HCPCS	761	RC		both	246	209.1	SelectHealth	Default	Percent of Total Billed Charges	233.7				85.5	238.62
REMOVAL SKIN TAGS<15 EA ADD 10 TAGS	11201	HCPCS	761	RC		both	235.5	200.18	Blue Cross of ID	Default	Percent of Total Billed Charges	228.44				17.07	228.44
REMOVAL SKIN TAGS<15 EA ADD 10 TAGS	11201	HCPCS	761	RC		both	235.5	200.18	Medicaid Idaho	Default	Fee Schedule	108.33				17.07	228.44
REMOVAL SKIN TAGS<15 EA ADD 10 TAGS	11201	HCPCS	761	RC		both	235.5	200.18	Medicare A ID JF	Default	Other	91.85		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	17.07	228.44
REMOVAL SKIN TAGS<15 EA ADD 10 TAGS	11201	HCPCS	761	RC		both	235.5	200.18	Medicare B ID JF	Default	Fee Schedule	17.07		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		17.07	228.44
REMOVAL SKIN TAGS<15 EA ADD 10 TAGS	11201	HCPCS	761	RC		both	235.5	200.18	Regence Group Administrators	Default	Fee Schedule	228.44				17.07	228.44
REMOVAL SKIN TAGS<15 EA ADD 10 TAGS	11201	HCPCS	761	RC		both	235.5	200.18	SelectHealth	Default	Percent of Total Billed Charges	223.72				17.07	228.44
SHAVE SKIN LESION	11300	HCPCS	761	RC		both	182	154.7	Blue Cross of ID	Default	Percent of Total Billed Charges	176.54				70.98	176.54
SHAVE SKIN LESION	11300	HCPCS	761	RC		both	182	154.7	Medicaid Idaho	Default	Fee Schedule	83.72				70.98	176.54
SHAVE SKIN LESION	11300	HCPCS	761	RC		both	182	154.7	Medicare A ID JF	Default	Other	70.98		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	70.98	176.54
SHAVE SKIN LESION	11300	HCPCS	761	RC		both	182	154.7	Medicare B ID JF	Default	Fee Schedule	92.08		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		70.98	176.54
SHAVE SKIN LESION	11300	HCPCS	761	RC		both	182	154.7	Regence Group Administrators	Default	Fee Schedule	176.54				70.98	176.54
SHAVE SKIN LESION	11300	HCPCS	761	RC		both	182	154.7	SelectHealth	Default	Percent of Total Billed Charges	172.9				70.98	176.54
SHAVE SKIN LESION 1.1 >2.0CM	11302	HCPCS	761	RC		both	182	154.7	Blue Cross of ID	Default	Percent of Total Billed Charges	176.54				70.98	176.54
SHAVE SKIN LESION 1.1 >2.0CM	11302	HCPCS	761	RC		both	182	154.7	Medicaid Idaho	Default	Fee Schedule	83.72				70.98	176.54
SHAVE SKIN LESION 1.1 >2.0CM	11302	HCPCS	761	RC		both	182	154.7	Medicare A ID JF	Default	Other	70.98		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	70.98	176.54
SHAVE SKIN LESION 1.1 >2.0CM	11302	HCPCS	761	RC		both	182	154.7	Medicare B ID JF	Default	Fee Schedule	126.11		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		70.98	176.54
SHAVE SKIN LESION 1.1 >2.0CM	11302	HCPCS	761	RC		both	182	154.7	Regence Group Administrators	Default	Fee Schedule	176.54				70.98	176.54
SHAVE SKIN LESION 1.1 >2.0CM	11302	HCPCS	761	RC		both	182	154.7	SelectHealth	Default	Percent of Total Billed Charges	172.9				70.98	176.54
SHAVE SKIN LESION SNHFG .6-1.0CM	11306	HCPCS	761	RC		both	182	154.7	Blue Cross of ID	Default	Percent of Total Billed Charges	176.54				70.98	176.54
SHAVE SKIN LESION SNHFG .6-1.0CM	11306	HCPCS	761	RC		both	182	154.7	Medicaid Idaho	Default	Fee Schedule	83.72				70.98	176.54
SHAVE SKIN LESION SNHFG .6-1.0CM	11306	HCPCS	761	RC		both	182	154.7	Medicare A ID JF	Default	Other	70.98		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	70.98	176.54
SHAVE SKIN LESION SNHFG .6-1.0CM	11306	HCPCS	761	RC		both	182	154.7	Medicare B ID JF	Default	Fee Schedule	112.83		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		70.98	176.54
SHAVE SKIN LESION SNHFG .6-1.0CM	11306	HCPCS	761	RC		both	182	154.7	Regence Group Administrators	Default	Fee Schedule	176.54				70.98	176.54
SHAVE SKIN LESION SNHFG .6-1.0CM	11306	HCPCS	761	RC		both	182	154.7	SelectHealth	Default	Percent of Total Billed Charges	172.9				70.98	176.54
SHAVE SKIN LESION FEENLM	11310	HCPCS	761	RC		both	182	154.7	Blue Cross of ID	Default	Percent of Total Billed Charges	176.54				70.98	176.54
SHAVE SKIN LESION FEENLM	11310	HCPCS	761	RC		both	182	154.7	Medicaid Idaho	Default	Fee Schedule	83.72				70.98	176.54
SHAVE SKIN LESION FEENLM	11310	HCPCS	761	RC		both	182	154.7	Medicare A ID JF	Default	Other	70.98		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	70.98	176.54
SHAVE SKIN LESION FEENLM	11310	HCPCS	761	RC		both	182	154.7	Medicare B ID JF	Default	Fee Schedule	106.29		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		70.98	176.54
SHAVE SKIN LESION FEENLM	11310	HCPCS	761	RC		both	182	154.7	Regence Group Administrators	Default	Fee Schedule	176.54				70.98	176.54
SHAVE SKIN LESION FEENLM	11310	HCPCS	761	RC		both	182	154.7	SelectHealth	Default	Percent of Total Billed Charges	172.9				70.98	176.54
SHAVE SKIN LESION FEENLM 0.6-1.0	11311	HCPCS	761	RC		both	182	154.7	Blue Cross of ID	Default	Percent of Total Billed Charges	176.54				70.98	176.54
SHAVE SKIN LESION FEENLM 0.6-1.0	11311	HCPCS	761	RC		both	182	154.7	Medicaid Idaho	Default	Fee Schedule	83.72				70.98	176.54
SHAVE SKIN LESION FEENLM 0.6-1.0	11311	HCPCS	761	RC		both	182	154.7	Medicare A ID JF	Default	Other	70.98		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	70.98	176.54
SHAVE SKIN LESION FEENLM 0.6-1.0	11311	HCPCS	761	RC		both	182	154.7	Medicare B ID JF	Default	Fee Schedule	125.81		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		70.98	176.54
SHAVE SKIN LESION FEENLM 0.6-1.0	11311	HCPCS	761	RC		both	182	154.7	Regence Group Administrators	Default	Fee Schedule	176.54				70.98	176.54
SHAVE SKIN LESION FEENLM 0.6-1.0	11311	HCPCS	761	RC		both	182	154.7	SelectHealth	Default	Percent of Total Billed Charges	172.9				70.98	176.54
SHAVE SKIN LESION >2.0 CM	11313	HCPCS	761	RC		both	238	202.3	Blue Cross of ID	Default	Percent of Total Billed Charges	230.86				92.82	230.86
SHAVE SKIN LESION >2.0 CM	11313	HCPCS	761	RC		both	238	202.3	Medicaid Idaho	Default	Fee Schedule	109.48				92.82	230.86
SHAVE SKIN LESION >2.0 CM	11313	HCPCS	761	RC		both	238	202.3	Medicare A ID JF	Default	Other	92.82		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	92.82	230.86
SHAVE SKIN LESION >2.0 CM	11313	HCPCS	761	RC		both	238	202.3	Medicare B ID JF	Default	Fee Schedule	166.74		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		92.82	230.86
SHAVE SKIN LESION >2.0 CM	11313	HCPCS	761	RC		both	238	202.3	Regence Group Administrators	Default	Fee Schedule	230.86				92.82	230.86
SHAVE SKIN LESION >2.0 CM	11313	HCPCS	761	RC		both	238	202.3	SelectHealth	Default	Percent of Total Billed Charges	226.1				92.82	230.86
"EXC BENIGN LESION T,A,L <.5CM"	11400	HCPCS	761	RC		both	355.5	302.18	Blue Cross of ID	Default	Percent of Total Billed Charges	344.84				117.94	344.84
"EXC BENIGN LESION T,A,L <.5CM"	11400	HCPCS	761	RC		both	355.5	302.18	Medicaid Idaho	Default	Fee Schedule	163.53				117.94	344.84
"EXC BENIGN LESION T,A,L <.5CM"	11400	HCPCS	761	RC		both	355.5	302.18	Medicare A ID JF	Default	Other	138.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	117.94	344.84
"EXC BENIGN LESION T,A,L <.5CM"	11400	HCPCS	761	RC		both	355.5	302.18	Medicare B ID JF	Default	Fee Schedule	117.94		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		117.94	344.84
"EXC BENIGN LESION T,A,L <.5CM"	11400	HCPCS	761	RC		both	355.5	302.18	Regence Group Administrators	Default	Fee Schedule	344.84				117.94	344.84
"EXC BENIGN LESION T,A,L <.5CM"	11400	HCPCS	761	RC		both	355.5	302.18	SelectHealth	Default	Percent of Total Billed Charges	337.72				117.94	344.84
"EXC BENIGN LESION T,A,L 06-1.0CM"	11401	HCPCS	761	RC		both	355.5	302.18	Blue Cross of ID	Default	Percent of Total Billed Charges	344.84				138.65	344.84
"EXC BENIGN LESION T,A,L 06-1.0CM"	11401	HCPCS	761	RC		both	355.5	302.18	Medicaid Idaho	Default	Fee Schedule	163.53				138.65	344.84
"EXC BENIGN LESION T,A,L 06-1.0CM"	11401	HCPCS	761	RC		both	355.5	302.18	Medicare A ID JF	Default	Other	138.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	138.65	344.84
"EXC BENIGN LESION T,A,L 06-1.0CM"	11401	HCPCS	761	RC		both	355.5	302.18	Medicare B ID JF	Default	Fee Schedule	143.9		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		138.65	344.84
"EXC BENIGN LESION T,A,L 06-1.0CM"	11401	HCPCS	761	RC		both	355.5	302.18	Regence Group Administrators	Default	Fee Schedule	344.84				138.65	344.84
"EXC BENIGN LESION T,A,L 06-1.0CM"	11401	HCPCS	761	RC		both	355.5	302.18	SelectHealth	Default	Percent of Total Billed Charges	337.72				138.65	344.84
"EXC BENIGN LESION T,A,L 1.1-2.0CM"	11402	HCPCS	761	RC		both	375	318.75	Blue Cross of ID	Default	Percent of Total Billed Charges	363.75				146.25	363.75
"EXC BENIGN LESION T,A,L 1.1-2.0CM"	11402	HCPCS	761	RC		both	375	318.75	Medicaid Idaho	Default	Fee Schedule	172.5				146.25	363.75
"EXC BENIGN LESION T,A,L 1.1-2.0CM"	11402	HCPCS	761	RC		both	375	318.75	Medicare A ID JF	Default	Other	146.25		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	146.25	363.75
"EXC BENIGN LESION T,A,L 1.1-2.0CM"	11402	HCPCS	761	RC		both	375	318.75	Medicare B ID JF	Default	Fee Schedule	158.48		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		146.25	363.75
"EXC BENIGN LESION T,A,L 1.1-2.0CM"	11402	HCPCS	761	RC		both	375	318.75	Regence Group Administrators	Default	Fee Schedule	363.75				146.25	363.75
"EXC BENIGN LESION T,A,L 1.1-2.0CM"	11402	HCPCS	761	RC		both	375	318.75	SelectHealth	Default	Percent of Total Billed Charges	356.25				146.25	363.75
"EXC BENIGN LESION T,A,L 2.1-3.0CM"	11403	HCPCS	761	RC		both	355.5	302.18	Blue Cross of ID	Default	Percent of Total Billed Charges	344.84				138.65	344.84
"EXC BENIGN LESION T,A,L 2.1-3.0CM"	11403	HCPCS	761	RC		both	355.5	302.18	Medicaid Idaho	Default	Fee Schedule	163.53				138.65	344.84
"EXC BENIGN LESION T,A,L 2.1-3.0CM"	11403	HCPCS	761	RC		both	355.5	302.18	Medicare A ID JF	Default	Other	138.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	138.65	344.84
"EXC BENIGN LESION T,A,L 2.1-3.0CM"	11403	HCPCS	761	RC		both	355.5	302.18	Medicare B ID JF	Default	Fee Schedule	182.36		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		138.65	344.84
"EXC BENIGN LESION T,A,L 2.1-3.0CM"	11403	HCPCS	761	RC		both	355.5	302.18	Regence Group Administrators	Default	Fee Schedule	344.84				138.65	344.84
"EXC BENIGN LESION T,A,L 2.1-3.0CM"	11403	HCPCS	761	RC		both	355.5	302.18	SelectHealth	Default	Percent of Total Billed Charges	337.72				138.65	344.84
"EXC BENIGN LESION T,A,L 3.1-4.0CM"	11404	HCPCS	761	RC		both	355.5	302.18	Blue Cross of ID	Default	Percent of Total Billed Charges	344.84				138.65	344.84
"EXC BENIGN LESION T,A,L 3.1-4.0CM"	11404	HCPCS	761	RC		both	355.5	302.18	Medicaid Idaho	Default	Fee Schedule	163.53				138.65	344.84
"EXC BENIGN LESION T,A,L 3.1-4.0CM"	11404	HCPCS	761	RC		both	355.5	302.18	Medicare A ID JF	Default	Other	138.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	138.65	344.84
"EXC BENIGN LESION T,A,L 3.1-4.0CM"	11404	HCPCS	761	RC		both	355.5	302.18	Medicare B ID JF	Default	Fee Schedule	205.88		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		138.65	344.84
"EXC BENIGN LESION T,A,L 3.1-4.0CM"	11404	HCPCS	761	RC		both	355.5	302.18	Regence Group Administrators	Default	Fee Schedule	344.84				138.65	344.84
"EXC BENIGN LESION T,A,L 3.1-4.0CM"	11404	HCPCS	761	RC		both	355.5	302.18	SelectHealth	Default	Percent of Total Billed Charges	337.72				138.65	344.84
"EXC BENIGN LESION T,A,L >4.0CM"	11406	HCPCS	761	RC		both	355.5	302.18	Blue Cross of ID	Default	Percent of Total Billed Charges	344.84				138.65	344.84
"EXC BENIGN LESION T,A,L >4.0CM"	11406	HCPCS	761	RC		both	355.5	302.18	Medicaid Idaho	Default	Fee Schedule	163.53				138.65	344.84
"EXC BENIGN LESION T,A,L >4.0CM"	11406	HCPCS	761	RC		both	355.5	302.18	Medicare A ID JF	Default	Other	138.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	138.65	344.84
"EXC BENIGN LESION T,A,L >4.0CM"	11406	HCPCS	761	RC		both	355.5	302.18	Medicare B ID JF	Default	Fee Schedule	292.03		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		138.65	344.84
"EXC BENIGN LESION T,A,L >4.0CM"	11406	HCPCS	761	RC		both	355.5	302.18	Regence Group Administrators	Default	Fee Schedule	344.84				138.65	344.84
"EXC BENIGN LESION T,A,L >4.0CM"	11406	HCPCS	761	RC		both	355.5	302.18	SelectHealth	Default	Percent of Total Billed Charges	337.72				138.65	344.84
EXC BENIGN LESION SNHFG <.5CM	11420	HCPCS	761	RC		both	355.5	302.18	Blue Cross of ID	Default	Percent of Total Billed Charges	344.84				117.13	344.84
EXC BENIGN LESION SNHFG <.5CM	11420	HCPCS	761	RC		both	355.5	302.18	Medicaid Idaho	Default	Fee Schedule	163.53				117.13	344.84
EXC BENIGN LESION SNHFG <.5CM	11420	HCPCS	761	RC		both	355.5	302.18	Medicare A ID JF	Default	Other	138.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	117.13	344.84
EXC BENIGN LESION SNHFG <.5CM	11420	HCPCS	761	RC		both	355.5	302.18	Medicare B ID JF	Default	Fee Schedule	117.13		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		117.13	344.84
EXC BENIGN LESION SNHFG <.5CM	11420	HCPCS	761	RC		both	355.5	302.18	Regence Group Administrators	Default	Fee Schedule	344.84				117.13	344.84
EXC BENIGN LESION SNHFG <.5CM	11420	HCPCS	761	RC		both	355.5	302.18	SelectHealth	Default	Percent of Total Billed Charges	337.72				117.13	344.84
EXC BENIGN LESION SNHFG .6-1.0CM	11421	HCPCS	761	RC		both	355.5	302.18	Blue Cross of ID	Default	Percent of Total Billed Charges	344.84				138.65	344.84
EXC BENIGN LESION SNHFG .6-1.0CM	11421	HCPCS	761	RC		both	355.5	302.18	Medicaid Idaho	Default	Fee Schedule	163.53				138.65	344.84
EXC BENIGN LESION SNHFG .6-1.0CM	11421	HCPCS	761	RC		both	355.5	302.18	Medicare A ID JF	Default	Other	138.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	138.65	344.84
EXC BENIGN LESION SNHFG .6-1.0CM	11421	HCPCS	761	RC		both	355.5	302.18	Medicare B ID JF	Default	Fee Schedule	147.66		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		138.65	344.84
EXC BENIGN LESION SNHFG .6-1.0CM	11421	HCPCS	761	RC		both	355.5	302.18	Regence Group Administrators	Default	Fee Schedule	344.84				138.65	344.84
EXC BENIGN LESION SNHFG .6-1.0CM	11421	HCPCS	761	RC		both	355.5	302.18	SelectHealth	Default	Percent of Total Billed Charges	337.72				138.65	344.84
EXC BENIGN LESION SNHFG 1.1-2.0CM	11422	HCPCS	761	RC		both	355.5	302.18	Blue Cross of ID	Default	Percent of Total Billed Charges	344.84				138.65	344.84
EXC BENIGN LESION SNHFG 1.1-2.0CM	11422	HCPCS	761	RC		both	355.5	302.18	Medicaid Idaho	Default	Fee Schedule	163.53				138.65	344.84
EXC BENIGN LESION SNHFG 1.1-2.0CM	11422	HCPCS	761	RC		both	355.5	302.18	Medicare A ID JF	Default	Other	138.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	138.65	344.84
EXC BENIGN LESION SNHFG 1.1-2.0CM	11422	HCPCS	761	RC		both	355.5	302.18	Medicare B ID JF	Default	Fee Schedule	165.54		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		138.65	344.84
EXC BENIGN LESION SNHFG 1.1-2.0CM	11422	HCPCS	761	RC		both	355.5	302.18	Regence Group Administrators	Default	Fee Schedule	344.84				138.65	344.84
EXC BENIGN LESION SNHFG 1.1-2.0CM	11422	HCPCS	761	RC		both	355.5	302.18	SelectHealth	Default	Percent of Total Billed Charges	337.72				138.65	344.84
EXC BENIGN LESION SNHFG 2.1-3.0CM	11423	HCPCS	761	RC		both	355.5	302.18	Blue Cross of ID	Default	Percent of Total Billed Charges	344.84				138.65	344.84
EXC BENIGN LESION SNHFG 2.1-3.0CM	11423	HCPCS	761	RC		both	355.5	302.18	Medicaid Idaho	Default	Fee Schedule	163.53				138.65	344.84
EXC BENIGN LESION SNHFG 2.1-3.0CM	11423	HCPCS	761	RC		both	355.5	302.18	Medicare A ID JF	Default	Other	138.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	138.65	344.84
EXC BENIGN LESION SNHFG 2.1-3.0CM	11423	HCPCS	761	RC		both	355.5	302.18	Medicare B ID JF	Default	Fee Schedule	189.69		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		138.65	344.84
EXC BENIGN LESION SNHFG 2.1-3.0CM	11423	HCPCS	761	RC		both	355.5	302.18	Regence Group Administrators	Default	Fee Schedule	344.84				138.65	344.84
EXC BENIGN LESION SNHFG 2.1-3.0CM	11423	HCPCS	761	RC		both	355.5	302.18	SelectHealth	Default	Percent of Total Billed Charges	337.72				138.65	344.84
EXC BENIGN LESION SNHFG 3.1-4.0CM	11424	HCPCS	761	RC		both	355.5	302.18	Blue Cross of ID	Default	Percent of Total Billed Charges	344.84				138.65	344.84
EXC BENIGN LESION SNHFG 3.1-4.0CM	11424	HCPCS	761	RC		both	355.5	302.18	Medicaid Idaho	Default	Fee Schedule	163.53				138.65	344.84
EXC BENIGN LESION SNHFG 3.1-4.0CM	11424	HCPCS	761	RC		both	355.5	302.18	Medicare A ID JF	Default	Other	138.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	138.65	344.84
EXC BENIGN LESION SNHFG 3.1-4.0CM	11424	HCPCS	761	RC		both	355.5	302.18	Medicare B ID JF	Default	Fee Schedule	219.11		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		138.65	344.84
EXC BENIGN LESION SNHFG 3.1-4.0CM	11424	HCPCS	761	RC		both	355.5	302.18	Regence Group Administrators	Default	Fee Schedule	344.84				138.65	344.84
EXC BENIGN LESION SNHFG 3.1-4.0CM	11424	HCPCS	761	RC		both	355.5	302.18	SelectHealth	Default	Percent of Total Billed Charges	337.72				138.65	344.84
EXC BENIGN LESION SNHFG >4.0CM	11426	HCPCS	761	RC		both	355.5	302.18	Blue Cross of ID	Default	Percent of Total Billed Charges	344.84				138.65	344.84
EXC BENIGN LESION SNHFG >4.0CM	11426	HCPCS	761	RC		both	355.5	302.18	Medicaid Idaho	Default	Fee Schedule	163.53				138.65	344.84
EXC BENIGN LESION SNHFG >4.0CM	11426	HCPCS	761	RC		both	355.5	302.18	Medicare A ID JF	Default	Other	138.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	138.65	344.84
EXC BENIGN LESION SNHFG >4.0CM	11426	HCPCS	761	RC		both	355.5	302.18	Medicare B ID JF	Default	Fee Schedule	302.08		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		138.65	344.84
EXC BENIGN LESION SNHFG >4.0CM	11426	HCPCS	761	RC		both	355.5	302.18	Regence Group Administrators	Default	Fee Schedule	344.84				138.65	344.84
EXC BENIGN LESION SNHFG >4.0CM	11426	HCPCS	761	RC		both	355.5	302.18	SelectHealth	Default	Percent of Total Billed Charges	337.72				138.65	344.84
EXC BENIGN LESION FEENL <.5CM	11640	HCPCS	761	RC		both	355.5	302.18	Blue Cross of ID	Default	Percent of Total Billed Charges	344.84				138.65	344.84
EXC BENIGN LESION FEENL <.5CM	11640	HCPCS	761	RC		both	355.5	302.18	Medicaid Idaho	Default	Fee Schedule	163.53				138.65	344.84
EXC BENIGN LESION FEENL <.5CM	11640	HCPCS	761	RC		both	355.5	302.18	Medicare A ID JF	Default	Other	138.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	138.65	344.84
EXC BENIGN LESION FEENL <.5CM	11640	HCPCS	761	RC		both	355.5	302.18	Medicare B ID JF	Default	Fee Schedule	187.27		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		138.65	344.84
EXC BENIGN LESION FEENL <.5CM	11640	HCPCS	761	RC		both	355.5	302.18	Regence Group Administrators	Default	Fee Schedule	344.84				138.65	344.84
EXC BENIGN LESION FEENL <.5CM	11640	HCPCS	761	RC		both	355.5	302.18	SelectHealth	Default	Percent of Total Billed Charges	337.72				138.65	344.84
EXC BENIGN LESION FEENL .6-1.0CM	11441	HCPCS	761	RC		both	355.5	302.18	Blue Cross of ID	Default	Percent of Total Billed Charges	344.84				138.65	344.84
EXC BENIGN LESION FEENL .6-1.0CM	11441	HCPCS	761	RC		both	355.5	302.18	Medicaid Idaho	Default	Fee Schedule	163.53				138.65	344.84
EXC BENIGN LESION FEENL .6-1.0CM	11441	HCPCS	761	RC		both	355.5	302.18	Medicare A ID JF	Default	Other	138.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	138.65	344.84
EXC BENIGN LESION FEENL .6-1.0CM	11441	HCPCS	761	RC		both	355.5	302.18	Medicare B ID JF	Default	Fee Schedule	160.69		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		138.65	344.84
EXC BENIGN LESION FEENL .6-1.0CM	11441	HCPCS	761	RC		both	355.5	302.18	Regence Group Administrators	Default	Fee Schedule	344.84				138.65	344.84
EXC BENIGN LESION FEENL .6-1.0CM	11441	HCPCS	761	RC		both	355.5	302.18	SelectHealth	Default	Percent of Total Billed Charges	337.72				138.65	344.84
EXC BENIGN LESION FEENL 1.1-2.0CM	11642	HCPCS	761	RC		both	355.5	302.18	Blue Cross of ID	Default	Percent of Total Billed Charges	344.84				138.65	344.84
EXC BENIGN LESION FEENL 1.1-2.0CM	11642	HCPCS	761	RC		both	355.5	302.18	Medicaid Idaho	Default	Fee Schedule	163.53				138.65	344.84
EXC BENIGN LESION FEENL 1.1-2.0CM	11642	HCPCS	761	RC		both	355.5	302.18	Medicare A ID JF	Default	Other	138.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	138.65	344.84
EXC BENIGN LESION FEENL 1.1-2.0CM	11642	HCPCS	761	RC		both	355.5	302.18	Medicare B ID JF	Default	Fee Schedule	247.18		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		138.65	344.84
EXC BENIGN LESION FEENL 1.1-2.0CM	11642	HCPCS	761	RC		both	355.5	302.18	Regence Group Administrators	Default	Fee Schedule	344.84				138.65	344.84
EXC BENIGN LESION FEENL 1.1-2.0CM	11642	HCPCS	761	RC		both	355.5	302.18	SelectHealth	Default	Percent of Total Billed Charges	337.72				138.65	344.84
EXC BENIGN LESION FEENL 2.1-3.0CM	11643	HCPCS	761	RC		both	355.5	302.18	Blue Cross of ID	Default	Percent of Total Billed Charges	344.84				138.65	344.84
EXC BENIGN LESION FEENL 2.1-3.0CM	11643	HCPCS	761	RC		both	355.5	302.18	Medicaid Idaho	Default	Fee Schedule	163.53				138.65	344.84
EXC BENIGN LESION FEENL 2.1-3.0CM	11643	HCPCS	761	RC		both	355.5	302.18	Medicare A ID JF	Default	Other	138.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	138.65	344.84
EXC BENIGN LESION FEENL 2.1-3.0CM	11643	HCPCS	761	RC		both	355.5	302.18	Medicare B ID JF	Default	Fee Schedule	290.16		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		138.65	344.84
EXC BENIGN LESION FEENL 2.1-3.0CM	11643	HCPCS	761	RC		both	355.5	302.18	Regence Group Administrators	Default	Fee Schedule	344.84				138.65	344.84
EXC BENIGN LESION FEENL 2.1-3.0CM	11643	HCPCS	761	RC		both	355.5	302.18	SelectHealth	Default	Percent of Total Billed Charges	337.72				138.65	344.84
EXC BENIGN LESION FEENL 3.1-4.0CM	11644	HCPCS	761	RC		both	355.5	302.18	Blue Cross of ID	Default	Percent of Total Billed Charges	344.84				138.65	355.5
EXC BENIGN LESION FEENL 3.1-4.0CM	11644	HCPCS	761	RC		both	355.5	302.18	Medicaid Idaho	Default	Fee Schedule	163.53				138.65	355.5
EXC BENIGN LESION FEENL 3.1-4.0CM	11644	HCPCS	761	RC		both	355.5	302.18	Medicare A ID JF	Default	Other	138.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	138.65	355.5
EXC BENIGN LESION FEENL 3.1-4.0CM	11644	HCPCS	761	RC		both	355.5	302.18	Medicare B ID JF	Default	Fee Schedule	355.5		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		138.65	355.5
EXC BENIGN LESION FEENL 3.1-4.0CM	11644	HCPCS	761	RC		both	355.5	302.18	Regence Group Administrators	Default	Fee Schedule	344.84				138.65	355.5
EXC BENIGN LESION FEENL 3.1-4.0CM	11644	HCPCS	761	RC		both	355.5	302.18	SelectHealth	Default	Percent of Total Billed Charges	337.72				138.65	355.5
EXC BENIGN LESION FEENL >4.0CM	11646	HCPCS	761	RC		both	355.5	302.18	Blue Cross of ID	Default	Percent of Total Billed Charges	344.84				138.65	355.5
EXC BENIGN LESION FEENL >4.0CM	11646	HCPCS	761	RC		both	355.5	302.18	Medicaid Idaho	Default	Fee Schedule	163.53				138.65	355.5
EXC BENIGN LESION FEENL >4.0CM	11646	HCPCS	761	RC		both	355.5	302.18	Medicare A ID JF	Default	Other	138.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	138.65	355.5
EXC BENIGN LESION FEENL >4.0CM	11646	HCPCS	761	RC		both	355.5	302.18	Medicare B ID JF	Default	Fee Schedule	355.5		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		138.65	355.5
EXC BENIGN LESION FEENL >4.0CM	11646	HCPCS	761	RC		both	355.5	302.18	Regence Group Administrators	Default	Fee Schedule	344.84				138.65	355.5
EXC BENIGN LESION FEENL >4.0CM	11646	HCPCS	761	RC		both	355.5	302.18	SelectHealth	Default	Percent of Total Billed Charges	337.72				138.65	355.5
"EXC LESION T,A,L <.5"	11600	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				181.56	549.99
"EXC LESION T,A,L <.5"	11600	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				181.56	549.99
"EXC LESION T,A,L <.5"	11600	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	181.56	549.99
"EXC LESION T,A,L <.5"	11600	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	181.56		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		181.56	549.99
"EXC LESION T,A,L <.5"	11600	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				181.56	549.99
"EXC LESION T,A,L <.5"	11600	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				181.56	549.99
"EXC LESION T,A,L .6-1.00CM"	11601	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				210.87	549.99
"EXC LESION T,A,L .6-1.00CM"	11601	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				210.87	549.99
"EXC LESION T,A,L .6-1.00CM"	11601	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	210.87	549.99
"EXC LESION T,A,L .6-1.00CM"	11601	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	210.87		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		210.87	549.99
"EXC LESION T,A,L .6-1.00CM"	11601	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				210.87	549.99
"EXC LESION T,A,L .6-1.00CM"	11601	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				210.87	549.99
"EXC LESION T,A,L 1.1-2.0CM"	11602	HCPCS	761	RC		both	355.5	302.18	Blue Cross of ID	Default	Percent of Total Billed Charges	344.84				138.65	344.84
"EXC LESION T,A,L 1.1-2.0CM"	11602	HCPCS	761	RC		both	355.5	302.18	Medicaid Idaho	Default	Fee Schedule	163.53				138.65	344.84
"EXC LESION T,A,L 1.1-2.0CM"	11602	HCPCS	761	RC		both	355.5	302.18	Medicare A ID JF	Default	Other	138.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	138.65	344.84
"EXC LESION T,A,L 1.1-2.0CM"	11602	HCPCS	761	RC		both	355.5	302.18	Medicare B ID JF	Default	Fee Schedule	225.99		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		138.65	344.84
"EXC LESION T,A,L 1.1-2.0CM"	11602	HCPCS	761	RC		both	355.5	302.18	Regence Group Administrators	Default	Fee Schedule	344.84				138.65	344.84
"EXC LESION T,A,L 1.1-2.0CM"	11602	HCPCS	761	RC		both	355.5	302.18	SelectHealth	Default	Percent of Total Billed Charges	337.72				138.65	344.84
"EXC LESION T,A,L 2.1-3.0"	11603	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				221.13	549.99
"EXC LESION T,A,L 2.1-3.0"	11603	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				221.13	549.99
"EXC LESION T,A,L 2.1-3.0"	11603	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	221.13	549.99
"EXC LESION T,A,L 2.1-3.0"	11603	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	257.17		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		221.13	549.99
"EXC LESION T,A,L 2.1-3.0"	11603	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				221.13	549.99
"EXC LESION T,A,L 2.1-3.0"	11603	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				221.13	549.99
"EXC LESION T,A,L 3.1-4.0CM"	11604	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				221.13	549.99
"EXC LESION T,A,L 3.1-4.0CM"	11604	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				221.13	549.99
"EXC LESION T,A,L 3.1-4.0CM"	11604	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	221.13	549.99
"EXC LESION T,A,L 3.1-4.0CM"	11604	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	286.06		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		221.13	549.99
"EXC LESION T,A,L 3.1-4.0CM"	11604	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				221.13	549.99
"EXC LESION T,A,L 3.1-4.0CM"	11604	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				221.13	549.99
"EXC LESION T,A,L >4.0"	11606	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				221.13	549.99
"EXC LESION T,A,L >4.0"	11606	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				221.13	549.99
"EXC LESION T,A,L >4.0"	11606	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	221.13	549.99
"EXC LESION T,A,L >4.0"	11606	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	410.16		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		221.13	549.99
"EXC LESION T,A,L >4.0"	11606	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				221.13	549.99
"EXC LESION T,A,L >4.0"	11606	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				221.13	549.99
EXC LESION SNHFG <.5CM	11620	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				182.35	549.99
EXC LESION SNHFG <.5CM	11620	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				182.35	549.99
EXC LESION SNHFG <.5CM	11620	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	182.35	549.99
EXC LESION SNHFG <.5CM	11620	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	182.35		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		182.35	549.99
EXC LESION SNHFG <.5CM	11620	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				182.35	549.99
EXC LESION SNHFG <.5CM	11620	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				182.35	549.99
EXC LESION SNHFG .6-1.0CM	11621	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				211.36	549.99
EXC LESION SNHFG .6-1.0CM	11621	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				211.36	549.99
EXC LESION SNHFG .6-1.0CM	11621	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	211.36	549.99
EXC LESION SNHFG .6-1.0CM	11621	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	211.36		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		211.36	549.99
EXC LESION SNHFG .6-1.0CM	11621	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				211.36	549.99
EXC LESION SNHFG .6-1.0CM	11621	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				211.36	549.99
EXC LESION SNHFG 1.1-2.0CM	11622	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				221.13	549.99
EXC LESION SNHFG 1.1-2.0CM	11622	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				221.13	549.99
EXC LESION SNHFG 1.1-2.0CM	11622	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	221.13	549.99
EXC LESION SNHFG 1.1-2.0CM	11622	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	233.68		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		221.13	549.99
EXC LESION SNHFG 1.1-2.0CM	11622	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				221.13	549.99
EXC LESION SNHFG 1.1-2.0CM	11622	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				221.13	549.99
EXC LESION SNHFG 2.1-3.0CM	11623	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				221.13	549.99
EXC LESION SNHFG 2.1-3.0CM	11623	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				221.13	549.99
EXC LESION SNHFG 2.1-3.0CM	11623	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	221.13	549.99
EXC LESION SNHFG 2.1-3.0CM	11623	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	272.88		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		221.13	549.99
EXC LESION SNHFG 2.1-3.0CM	11623	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				221.13	549.99
EXC LESION SNHFG 2.1-3.0CM	11623	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				221.13	549.99
EXC LESION SNHFG 3.1-4.0cm	11624	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				221.13	549.99
EXC LESION SNHFG 3.1-4.0cm	11624	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				221.13	549.99
EXC LESION SNHFG 3.1-4.0cm	11624	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	221.13	549.99
EXC LESION SNHFG 3.1-4.0cm	11624	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	310.13		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		221.13	549.99
EXC LESION SNHFG 3.1-4.0cm	11624	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				221.13	549.99
EXC LESION SNHFG 3.1-4.0cm	11624	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				221.13	549.99
EXC LESION SNHF >4.0	11626	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				221.13	549.99
EXC LESION SNHF >4.0	11626	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				221.13	549.99
EXC LESION SNHF >4.0	11626	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	221.13	549.99
EXC LESION SNHF >4.0	11626	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	371.71		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		221.13	549.99
EXC LESION SNHF >4.0	11626	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				221.13	549.99
EXC LESION SNHF >4.0	11626	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				221.13	549.99
EXC LESION FEENL <.5CM	11640	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				187.27	549.99
EXC LESION FEENL <.5CM	11640	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				187.27	549.99
EXC LESION FEENL <.5CM	11640	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	187.27	549.99
EXC LESION FEENL <.5CM	11640	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	187.27		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		187.27	549.99
EXC LESION FEENL <.5CM	11640	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				187.27	549.99
EXC LESION FEENL <.5CM	11640	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				187.27	549.99
EXC LESION FEENL .6-1.0CM	11641	HCPCS	761	RC		both	355.5	302.18	Blue Cross of ID	Default	Percent of Total Billed Charges	344.84				138.65	344.84
EXC LESION FEENL .6-1.0CM	11641	HCPCS	761	RC		both	355.5	302.18	Medicaid Idaho	Default	Fee Schedule	163.53				138.65	344.84
EXC LESION FEENL .6-1.0CM	11641	HCPCS	761	RC		both	355.5	302.18	Medicare A ID JF	Default	Other	138.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	138.65	344.84
EXC LESION FEENL .6-1.0CM	11641	HCPCS	761	RC		both	355.5	302.18	Medicare B ID JF	Default	Fee Schedule	218.43		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		138.65	344.84
EXC LESION FEENL .6-1.0CM	11641	HCPCS	761	RC		both	355.5	302.18	Regence Group Administrators	Default	Fee Schedule	344.84				138.65	344.84
EXC LESION FEENL .6-1.0CM	11641	HCPCS	761	RC		both	355.5	302.18	SelectHealth	Default	Percent of Total Billed Charges	337.72				138.65	344.84
EXC LESION FEENL 1.1-2.0CM	11642	HCPCS	761	RC		both	355.5	302.18	Blue Cross of ID	Default	Percent of Total Billed Charges	344.84				138.65	344.84
EXC LESION FEENL 1.1-2.0CM	11642	HCPCS	761	RC		both	355.5	302.18	Medicaid Idaho	Default	Fee Schedule	163.53				138.65	344.84
EXC LESION FEENL 1.1-2.0CM	11642	HCPCS	761	RC		both	355.5	302.18	Medicare A ID JF	Default	Other	138.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	138.65	344.84
EXC LESION FEENL 1.1-2.0CM	11642	HCPCS	761	RC		both	355.5	302.18	Medicare B ID JF	Default	Fee Schedule	247.18		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		138.65	344.84
EXC LESION FEENL 1.1-2.0CM	11642	HCPCS	761	RC		both	355.5	302.18	Regence Group Administrators	Default	Fee Schedule	344.84				138.65	344.84
EXC LESION FEENL 1.1-2.0CM	11642	HCPCS	761	RC		both	355.5	302.18	SelectHealth	Default	Percent of Total Billed Charges	337.72				138.65	344.84
EXC LESION FEENL 2.1-3.0CM	11643	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				221.13	549.99
EXC LESION FEENL 2.1-3.0CM	11643	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				221.13	549.99
EXC LESION FEENL 2.1-3.0CM	11643	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	221.13	549.99
EXC LESION FEENL 2.1-3.0CM	11643	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	290.16		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		221.13	549.99
EXC LESION FEENL 2.1-3.0CM	11643	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				221.13	549.99
EXC LESION FEENL 2.1-3.0CM	11643	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				221.13	549.99
EXC LESION FEENL 3.1-4.0CM	11644	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				221.13	549.99
EXC LESION FEENL 3.1-4.0CM	11644	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				221.13	549.99
EXC LESION FEENL 3.1-4.0CM	11644	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	221.13	549.99
EXC LESION FEENL 3.1-4.0CM	11644	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	357.7		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		221.13	549.99
EXC LESION FEENL 3.1-4.0CM	11644	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				221.13	549.99
EXC LESION FEENL 3.1-4.0CM	11644	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				221.13	549.99
EXC LESION FEENL >4.0CM	11646	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				221.13	549.99
EXC LESION FEENL >4.0CM	11646	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				221.13	549.99
EXC LESION FEENL >4.0CM	11646	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	221.13	549.99
EXC LESION FEENL >4.0CM	11646	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	462.95		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		221.13	549.99
EXC LESION FEENL >4.0CM	11646	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				221.13	549.99
EXC LESION FEENL >4.0CM	11646	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				221.13	549.99
NAIL REMOVEL 1	11730	HCPCS	761	RC		both	416.5	354.03	Blue Cross of ID	Default	Percent of Total Billed Charges	404				106.46	404
NAIL REMOVEL 1	11730	HCPCS	761	RC		both	416.5	354.03	Medicaid Idaho	Default	Fee Schedule	191.59				106.46	404
NAIL REMOVEL 1	11730	HCPCS	761	RC		both	416.5	354.03	Medicare A ID JF	Default	Other	162.44		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	106.46	404
NAIL REMOVEL 1	11730	HCPCS	761	RC		both	416.5	354.03	Medicare B ID JF	Default	Fee Schedule	106.46		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		106.46	404
NAIL REMOVEL 1	11730	HCPCS	761	RC		both	416.5	354.03	Regence Group Administrators	Default	Fee Schedule	404				106.46	404
NAIL REMOVEL 1	11730	HCPCS	761	RC		both	416.5	354.03	SelectHealth	Default	Percent of Total Billed Charges	395.68				106.46	404
NAIL REMOVEL EA ADD	11732	HCPCS	761	RC		both	221.5	188.28	Blue Cross of ID	Default	Percent of Total Billed Charges	214.86				30.64	214.86
NAIL REMOVEL EA ADD	11732	HCPCS	761	RC		both	221.5	188.28	Medicaid Idaho	Default	Fee Schedule	101.89				30.64	214.86
NAIL REMOVEL EA ADD	11732	HCPCS	761	RC		both	221.5	188.28	Medicare A ID JF	Default	Other	86.39		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	30.64	214.86
NAIL REMOVEL EA ADD	11732	HCPCS	761	RC		both	221.5	188.28	Medicare B ID JF	Default	Fee Schedule	30.64		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		30.64	214.86
NAIL REMOVEL EA ADD	11732	HCPCS	761	RC		both	221.5	188.28	Regence Group Administrators	Default	Fee Schedule	214.86				30.64	214.86
NAIL REMOVEL EA ADD	11732	HCPCS	761	RC		both	221.5	188.28	SelectHealth	Default	Percent of Total Billed Charges	210.42				30.64	214.86
DRAIN BLOOD UNDER NAIL	11740	HCPCS	761	RC		both	219	186.15	Blue Cross of ID	Default	Percent of Total Billed Charges	212.43				53.28	212.43
DRAIN BLOOD UNDER NAIL	11740	HCPCS	761	RC		both	219	186.15	Medicaid Idaho	Default	Fee Schedule	100.74				53.28	212.43
DRAIN BLOOD UNDER NAIL	11740	HCPCS	761	RC		both	219	186.15	Medicare A ID JF	Default	Other	85.41		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	53.28	212.43
DRAIN BLOOD UNDER NAIL	11740	HCPCS	761	RC		both	219	186.15	Medicare B ID JF	Default	Fee Schedule	53.28		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		53.28	212.43
DRAIN BLOOD UNDER NAIL	11740	HCPCS	761	RC		both	219	186.15	Regence Group Administrators	Default	Fee Schedule	212.43				53.28	212.43
DRAIN BLOOD UNDER NAIL	11740	HCPCS	761	RC		both	219	186.15	SelectHealth	Default	Percent of Total Billed Charges	208.05				53.28	212.43
NAIL-MATRIX EXC	11750	HCPCS	761	RC		both	778.5	661.73	Blue Cross of ID	Default	Percent of Total Billed Charges	755.14				149.19	755.14
NAIL-MATRIX EXC	11750	HCPCS	761	RC		both	778.5	661.73	Medicaid Idaho	Default	Fee Schedule	358.11				149.19	755.14
NAIL-MATRIX EXC	11750	HCPCS	761	RC		both	778.5	661.73	Medicare A ID JF	Default	Other	303.62		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	149.19	755.14
NAIL-MATRIX EXC	11750	HCPCS	761	RC		both	778.5	661.73	Medicare B ID JF	Default	Fee Schedule	149.19		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		149.19	755.14
NAIL-MATRIX EXC	11750	HCPCS	761	RC		both	778.5	661.73	Regence Group Administrators	Default	Fee Schedule	755.14				149.19	755.14
NAIL-MATRIX EXC	11750	HCPCS	761	RC		both	778.5	661.73	SelectHealth	Default	Percent of Total Billed Charges	739.58				149.19	755.14
WEDGE-EXC SIN-TOENAIL	11765	HCPCS	761	RC		both	577.5	490.88	Blue Cross of ID	Default	Percent of Total Billed Charges	560.18				153.37	560.18
WEDGE-EXC SIN-TOENAIL	11765	HCPCS	761	RC		both	577.5	490.88	Medicaid Idaho	Default	Fee Schedule	265.65				153.37	560.18
WEDGE-EXC SIN-TOENAIL	11765	HCPCS	761	RC		both	577.5	490.88	Medicare A ID JF	Default	Other	225.23		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	153.37	560.18
WEDGE-EXC SIN-TOENAIL	11765	HCPCS	761	RC		both	577.5	490.88	Medicare B ID JF	Default	Fee Schedule	153.37		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		153.37	560.18
WEDGE-EXC SIN-TOENAIL	11765	HCPCS	761	RC		both	577.5	490.88	Regence Group Administrators	Default	Fee Schedule	560.18				153.37	560.18
WEDGE-EXC SIN-TOENAIL	11765	HCPCS	761	RC		both	577.5	490.88	SelectHealth	Default	Percent of Total Billed Charges	548.62				153.37	560.18
"LAYER CLOSE S,A,T,E 2.5CM >LESS"	12031	HCPCS	761	RC		both	400	340	Blue Cross of ID	Default	Percent of Total Billed Charges	388				156	388
"LAYER CLOSE S,A,T,E 2.5CM >LESS"	12031	HCPCS	761	RC		both	400	340	Medicaid Idaho	Default	Fee Schedule	184				156	388
"LAYER CLOSE S,A,T,E 2.5CM >LESS"	12031	HCPCS	761	RC		both	400	340	Medicare A ID JF	Default	Other	156		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	156	388
"LAYER CLOSE S,A,T,E 2.5CM >LESS"	12031	HCPCS	761	RC		both	400	340	Medicare B ID JF	Default	Fee Schedule	241.49		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		156	388
"LAYER CLOSE S,A,T,E 2.5CM >LESS"	12031	HCPCS	761	RC		both	400	340	Regence Group Administrators	Default	Fee Schedule	388				156	388
"LAYER CLOSE S,A,T,E 2.5CM >LESS"	12031	HCPCS	761	RC		both	400	340	SelectHealth	Default	Percent of Total Billed Charges	380				156	388
LAYER CLOSE SATE 2.6>7.5	12032	HCPCS	761	RC		both	572.5	486.63	Blue Cross of ID	Default	Percent of Total Billed Charges	555.32				223.28	555.32
LAYER CLOSE SATE 2.6>7.5	12032	HCPCS	761	RC		both	572.5	486.63	Medicaid Idaho	Default	Fee Schedule	263.35				223.28	555.32
LAYER CLOSE SATE 2.6>7.5	12032	HCPCS	761	RC		both	572.5	486.63	Medicare A ID JF	Default	Other	223.28		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	223.28	555.32
LAYER CLOSE SATE 2.6>7.5	12032	HCPCS	761	RC		both	572.5	486.63	Medicare B ID JF	Default	Fee Schedule	279.66		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		223.28	555.32
LAYER CLOSE SATE 2.6>7.5	12032	HCPCS	761	RC		both	572.5	486.63	Regence Group Administrators	Default	Fee Schedule	555.32				223.28	555.32
LAYER CLOSE SATE 2.6>7.5	12032	HCPCS	761	RC		both	572.5	486.63	SelectHealth	Default	Percent of Total Billed Charges	543.88				223.28	555.32
LAYER CLOSE SATE 7.6>12.5	12034	HCPCS	761	RC		both	705	599.25	Blue Cross of ID	Default	Percent of Total Billed Charges	683.85				274.95	683.85
LAYER CLOSE SATE 7.6>12.5	12034	HCPCS	761	RC		both	705	599.25	Medicaid Idaho	Default	Fee Schedule	324.3				274.95	683.85
LAYER CLOSE SATE 7.6>12.5	12034	HCPCS	761	RC		both	705	599.25	Medicare A ID JF	Default	Other	274.95		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	274.95	683.85
LAYER CLOSE SATE 7.6>12.5	12034	HCPCS	761	RC		both	705	599.25	Medicare B ID JF	Default	Fee Schedule	307.51		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		274.95	683.85
LAYER CLOSE SATE 7.6>12.5	12034	HCPCS	761	RC		both	705	599.25	Regence Group Administrators	Default	Fee Schedule	683.85				274.95	683.85
LAYER CLOSE SATE 7.6>12.5	12034	HCPCS	761	RC		both	705	599.25	SelectHealth	Default	Percent of Total Billed Charges	669.75				274.95	683.85
"LAYER CLOSE N,H,F,G 2.5>LESS"	12041	HCPCS	761	RC		both	540	459	Blue Cross of ID	Default	Percent of Total Billed Charges	523.8				210.6	523.8
"LAYER CLOSE N,H,F,G 2.5>LESS"	12041	HCPCS	761	RC		both	540	459	Medicaid Idaho	Default	Fee Schedule	248.4				210.6	523.8
"LAYER CLOSE N,H,F,G 2.5>LESS"	12041	HCPCS	761	RC		both	540	459	Medicare A ID JF	Default	Other	210.6		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	210.6	523.8
"LAYER CLOSE N,H,F,G 2.5>LESS"	12041	HCPCS	761	RC		both	540	459	Medicare B ID JF	Default	Fee Schedule	242.25		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		210.6	523.8
"LAYER CLOSE N,H,F,G 2.5>LESS"	12041	HCPCS	761	RC		both	540	459	Regence Group Administrators	Default	Fee Schedule	523.8				210.6	523.8
"LAYER CLOSE N,H,F,G 2.5>LESS"	12041	HCPCS	761	RC		both	540	459	SelectHealth	Default	Percent of Total Billed Charges	513				210.6	523.8
"LAYER CLOSE F,E,E,N,L 2.5CM>LESS"	12051	HCPCS	761	RC		both	430.5	365.93	Blue Cross of ID	Default	Percent of Total Billed Charges	417.58				167.9	417.58
"LAYER CLOSE F,E,E,N,L 2.5CM>LESS"	12051	HCPCS	761	RC		both	430.5	365.93	Medicaid Idaho	Default	Fee Schedule	198.03				167.9	417.58
"LAYER CLOSE F,E,E,N,L 2.5CM>LESS"	12051	HCPCS	761	RC		both	430.5	365.93	Medicare A ID JF	Default	Other	167.9		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	167.9	417.58
"LAYER CLOSE F,E,E,N,L 2.5CM>LESS"	12051	HCPCS	761	RC		both	430.5	365.93	Medicare B ID JF	Default	Fee Schedule	260.34		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		167.9	417.58
"LAYER CLOSE F,E,E,N,L 2.5CM>LESS"	12051	HCPCS	761	RC		both	430.5	365.93	Regence Group Administrators	Default	Fee Schedule	417.58				167.9	417.58
"LAYER CLOSE F,E,E,N,L 2.5CM>LESS"	12051	HCPCS	761	RC		both	430.5	365.93	SelectHealth	Default	Percent of Total Billed Charges	408.98				167.9	417.58
2X3 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	Blue Cross of ID	Default	Percent of Total Billed Charges	522.83				210.21	522.83
2X3 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	Medicaid Idaho	Default	Fee Schedule	247.94				210.21	522.83
2X3 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	Medicare A ID JF	Default	Other	210.21		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	210.21	522.83
2X3 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		210.21	522.83
2X3 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	Regence Group Administrators	Default	Fee Schedule	522.83				210.21	522.83
2X3 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	SelectHealth	Default	Percent of Total Billed Charges	512.05				210.21	522.83
APPLY SKIN GRAFT TO TRUNK 25 SQ CM OR LE	15271	HCPCS	761	RC		both	1760.5	1496.43	Blue Cross of ID	Default	Percent of Total Billed Charges	1707.68				141.26	1707.68
APPLY SKIN GRAFT TO TRUNK 25 SQ CM OR LE	15271	HCPCS	761	RC		both	1760.5	1496.43	Medicaid Idaho	Default	Fee Schedule	809.83				141.26	1707.68
APPLY SKIN GRAFT TO TRUNK 25 SQ CM OR LE	15271	HCPCS	761	RC		both	1760.5	1496.43	Medicare A ID JF	Default	Other	686.6		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	141.26	1707.68
APPLY SKIN GRAFT TO TRUNK 25 SQ CM OR LE	15271	HCPCS	761	RC		both	1760.5	1496.43	Medicare B ID JF	Default	Fee Schedule	141.26		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		141.26	1707.68
APPLY SKIN GRAFT TO TRUNK 25 SQ CM OR LE	15271	HCPCS	761	RC		both	1760.5	1496.43	Regence Group Administrators	Default	Fee Schedule	1707.68				141.26	1707.68
APPLY SKIN GRAFT TO TRUNK 25 SQ CM OR LE	15271	HCPCS	761	RC		both	1760.5	1496.43	SelectHealth	Default	Percent of Total Billed Charges	1672.48				141.26	1707.68
APPLY SKIN GRAFT TO TRUNK ADDTL 25 SQ CM	15272	HCPCS	761	RC		both	897	762.45	Blue Cross of ID	Default	Percent of Total Billed Charges	870.09				22.63	870.09
APPLY SKIN GRAFT TO TRUNK ADDTL 25 SQ CM	15272	HCPCS	761	RC		both	897	762.45	Medicaid Idaho	Default	Fee Schedule	412.62				22.63	870.09
APPLY SKIN GRAFT TO TRUNK ADDTL 25 SQ CM	15272	HCPCS	761	RC		both	897	762.45	Medicare A ID JF	Default	Other	349.83		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	22.63	870.09
APPLY SKIN GRAFT TO TRUNK ADDTL 25 SQ CM	15272	HCPCS	761	RC		both	897	762.45	Medicare B ID JF	Default	Fee Schedule	22.63		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		22.63	870.09
APPLY SKIN GRAFT TO TRUNK ADDTL 25 SQ CM	15272	HCPCS	761	RC		both	897	762.45	Regence Group Administrators	Default	Fee Schedule	870.09				22.63	870.09
APPLY SKIN GRAFT TO TRUNK ADDTL 25 SQ CM	15272	HCPCS	761	RC		both	897	762.45	SelectHealth	Default	Percent of Total Billed Charges	852.15				22.63	870.09
APPLY SKIN GRAFT TO TRUNK 100 SQ CM	15273	HCPCS	761	RC		both	3318	2820.3	Blue Cross of ID	Default	Percent of Total Billed Charges	3218.46				281.08	3218.46
APPLY SKIN GRAFT TO TRUNK 100 SQ CM	15273	HCPCS	761	RC		both	3318	2820.3	Medicaid Idaho	Default	Fee Schedule	1526.28				281.08	3218.46
APPLY SKIN GRAFT TO TRUNK 100 SQ CM	15273	HCPCS	761	RC		both	3318	2820.3	Medicare A ID JF	Default	Other	1294.02		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	281.08	3218.46
APPLY SKIN GRAFT TO TRUNK 100 SQ CM	15273	HCPCS	761	RC		both	3318	2820.3	Medicare B ID JF	Default	Fee Schedule	281.08		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		281.08	3218.46
APPLY SKIN GRAFT TO TRUNK 100 SQ CM	15273	HCPCS	761	RC		both	3318	2820.3	Regence Group Administrators	Default	Fee Schedule	3218.46				281.08	3218.46
APPLY SKIN GRAFT TO TRUNK 100 SQ CM	15273	HCPCS	761	RC		both	3318	2820.3	SelectHealth	Default	Percent of Total Billed Charges	3152.1				281.08	3218.46
APPLY SKIN GRAFT TO TRUNK ADDTL100 SQ CM	15274	HCPCS	761	RC		both	1659	1410.15	Blue Cross of ID	Default	Percent of Total Billed Charges	1609.23				73.37	1609.23
APPLY SKIN GRAFT TO TRUNK ADDTL100 SQ CM	15274	HCPCS	761	RC		both	1659	1410.15	Medicaid Idaho	Default	Fee Schedule	763.14				73.37	1609.23
APPLY SKIN GRAFT TO TRUNK ADDTL100 SQ CM	15274	HCPCS	761	RC		both	1659	1410.15	Medicare A ID JF	Default	Other	647.01		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	73.37	1609.23
APPLY SKIN GRAFT TO TRUNK ADDTL100 SQ CM	15274	HCPCS	761	RC		both	1659	1410.15	Medicare B ID JF	Default	Fee Schedule	73.37		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		73.37	1609.23
APPLY SKIN GRAFT TO TRUNK ADDTL100 SQ CM	15274	HCPCS	761	RC		both	1659	1410.15	Regence Group Administrators	Default	Fee Schedule	1609.23				73.37	1609.23
APPLY SKIN GRAFT TO TRUNK ADDTL100 SQ CM	15274	HCPCS	761	RC		both	1659	1410.15	SelectHealth	Default	Percent of Total Billed Charges	1576.05				73.37	1609.23
APPLY SKIN SUB TO FACE 25 OR LESS SQ CM	15275	HCPCS	761	RC		both	1760.5	1496.43	Blue Cross of ID	Default	Percent of Total Billed Charges	1707.68				146.95	1707.68
APPLY SKIN SUB TO FACE 25 OR LESS SQ CM	15275	HCPCS	761	RC		both	1760.5	1496.43	Medicaid Idaho	Default	Fee Schedule	809.83				146.95	1707.68
APPLY SKIN SUB TO FACE 25 OR LESS SQ CM	15275	HCPCS	761	RC		both	1760.5	1496.43	Medicare A ID JF	Default	Other	686.6		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	146.95	1707.68
APPLY SKIN SUB TO FACE 25 OR LESS SQ CM	15275	HCPCS	761	RC		both	1760.5	1496.43	Medicare B ID JF	Default	Fee Schedule	146.95		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		146.95	1707.68
APPLY SKIN SUB TO FACE 25 OR LESS SQ CM	15275	HCPCS	761	RC		both	1760.5	1496.43	Regence Group Administrators	Default	Fee Schedule	1707.68				146.95	1707.68
APPLY SKIN SUB TO FACE 25 OR LESS SQ CM	15275	HCPCS	761	RC		both	1760.5	1496.43	SelectHealth	Default	Percent of Total Billed Charges	1672.48				146.95	1707.68
APPLY SKIN SUB TO FACE  ADDTL 25  SQ CM	15276	HCPCS	761	RC		both	897	762.45	Blue Cross of ID	Default	Percent of Total Billed Charges	870.09				29.81	870.09
APPLY SKIN SUB TO FACE  ADDTL 25  SQ CM	15276	HCPCS	761	RC		both	897	762.45	Medicaid Idaho	Default	Fee Schedule	412.62				29.81	870.09
APPLY SKIN SUB TO FACE  ADDTL 25  SQ CM	15276	HCPCS	761	RC		both	897	762.45	Medicare A ID JF	Default	Other	349.83		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	29.81	870.09
APPLY SKIN SUB TO FACE  ADDTL 25  SQ CM	15276	HCPCS	761	RC		both	897	762.45	Medicare B ID JF	Default	Fee Schedule	29.81		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		29.81	870.09
APPLY SKIN SUB TO FACE  ADDTL 25  SQ CM	15276	HCPCS	761	RC		both	897	762.45	Regence Group Administrators	Default	Fee Schedule	870.09				29.81	870.09
APPLY SKIN SUB TO FACE  ADDTL 25  SQ CM	15276	HCPCS	761	RC		both	897	762.45	SelectHealth	Default	Percent of Total Billed Charges	852.15				29.81	870.09
APPLY SKIN SUB TO FACE 100 SQ CM	15277	HCPCS	761	RC		both	1760.5	1496.43	Blue Cross of ID	Default	Percent of Total Billed Charges	1707.68				310.44	1707.68
APPLY SKIN SUB TO FACE 100 SQ CM	15277	HCPCS	761	RC		both	1760.5	1496.43	Medicaid Idaho	Default	Fee Schedule	809.83				310.44	1707.68
APPLY SKIN SUB TO FACE 100 SQ CM	15277	HCPCS	761	RC		both	1760.5	1496.43	Medicare A ID JF	Default	Other	686.6		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	310.44	1707.68
APPLY SKIN SUB TO FACE 100 SQ CM	15277	HCPCS	761	RC		both	1760.5	1496.43	Medicare B ID JF	Default	Fee Schedule	310.44		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		310.44	1707.68
APPLY SKIN SUB TO FACE 100 SQ CM	15277	HCPCS	761	RC		both	1760.5	1496.43	Regence Group Administrators	Default	Fee Schedule	1707.68				310.44	1707.68
APPLY SKIN SUB TO FACE 100 SQ CM	15277	HCPCS	761	RC		both	1760.5	1496.43	SelectHealth	Default	Percent of Total Billed Charges	1672.48				310.44	1707.68
APPLY SKIN SUB TO FACE ADDTL100 SQ CM	15278	HCPCS	761	RC		both	897	762.45	Blue Cross of ID	Default	Percent of Total Billed Charges	870.09				85.93	870.09
APPLY SKIN SUB TO FACE ADDTL100 SQ CM	15278	HCPCS	761	RC		both	897	762.45	Medicaid Idaho	Default	Fee Schedule	412.62				85.93	870.09
APPLY SKIN SUB TO FACE ADDTL100 SQ CM	15278	HCPCS	761	RC		both	897	762.45	Medicare A ID JF	Default	Other	349.83		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	85.93	870.09
APPLY SKIN SUB TO FACE ADDTL100 SQ CM	15278	HCPCS	761	RC		both	897	762.45	Medicare B ID JF	Default	Fee Schedule	85.93		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		85.93	870.09
APPLY SKIN SUB TO FACE ADDTL100 SQ CM	15278	HCPCS	761	RC		both	897	762.45	Regence Group Administrators	Default	Fee Schedule	870.09				85.93	870.09
APPLY SKIN SUB TO FACE ADDTL100 SQ CM	15278	HCPCS	761	RC		both	897	762.45	SelectHealth	Default	Percent of Total Billed Charges	852.15				85.93	870.09
BURN DRESS/DEBRIDMENT SM	16020	HCPCS	761	RC		both	151	128.35	Blue Cross of ID	Default	Percent of Total Billed Charges	146.47				58.89	146.47
BURN DRESS/DEBRIDMENT SM	16020	HCPCS	761	RC		both	151	128.35	Medicaid Idaho	Default	Fee Schedule	69.46				58.89	146.47
BURN DRESS/DEBRIDMENT SM	16020	HCPCS	761	RC		both	151	128.35	Medicare A ID JF	Default	Other	58.89		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	58.89	146.47
BURN DRESS/DEBRIDMENT SM	16020	HCPCS	761	RC		both	151	128.35	Medicare B ID JF	Default	Fee Schedule	78.67		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		58.89	146.47
BURN DRESS/DEBRIDMENT SM	16020	HCPCS	761	RC		both	151	128.35	Regence Group Administrators	Default	Fee Schedule	146.47				58.89	146.47
BURN DRESS/DEBRIDMENT SM	16020	HCPCS	761	RC		both	151	128.35	SelectHealth	Default	Percent of Total Billed Charges	143.45				58.89	146.47
BURN DRESS/DEBRIDMENT MED	16025	HCPCS	761	RC		both	269.5	229.08	Blue Cross of ID	Default	Percent of Total Billed Charges	261.42				105.11	261.42
BURN DRESS/DEBRIDMENT MED	16025	HCPCS	761	RC		both	269.5	229.08	Medicaid Idaho	Default	Fee Schedule	123.97				105.11	261.42
BURN DRESS/DEBRIDMENT MED	16025	HCPCS	761	RC		both	269.5	229.08	Medicare A ID JF	Default	Other	105.11		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	105.11	261.42
BURN DRESS/DEBRIDMENT MED	16025	HCPCS	761	RC		both	269.5	229.08	Medicare B ID JF	Default	Fee Schedule	144.28		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		105.11	261.42
BURN DRESS/DEBRIDMENT MED	16025	HCPCS	761	RC		both	269.5	229.08	Regence Group Administrators	Default	Fee Schedule	261.42				105.11	261.42
BURN DRESS/DEBRIDMENT MED	16025	HCPCS	761	RC		both	269.5	229.08	SelectHealth	Default	Percent of Total Billed Charges	256.02				105.11	261.42
BURN DRESS/DEBRIDMENT LG	16030	HCPCS	761	RC		both	390	331.5	Blue Cross of ID	Default	Percent of Total Billed Charges	378.3				152.1	378.3
BURN DRESS/DEBRIDMENT LG	16030	HCPCS	761	RC		both	390	331.5	Medicaid Idaho	Default	Fee Schedule	179.4				152.1	378.3
BURN DRESS/DEBRIDMENT LG	16030	HCPCS	761	RC		both	390	331.5	Medicare A ID JF	Default	Other	152.1		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	152.1	378.3
BURN DRESS/DEBRIDMENT LG	16030	HCPCS	761	RC		both	390	331.5	Medicare B ID JF	Default	Fee Schedule	179.66		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		152.1	378.3
BURN DRESS/DEBRIDMENT LG	16030	HCPCS	761	RC		both	390	331.5	Regence Group Administrators	Default	Fee Schedule	378.3				152.1	378.3
BURN DRESS/DEBRIDMENT LG	16030	HCPCS	761	RC		both	390	331.5	SelectHealth	Default	Percent of Total Billed Charges	370.5				152.1	378.3
DESTRUCT BENIGN PREMAL LESION 1ST	17000	HCPCS	761	RC		both	355.5	302.18	Blue Cross of ID	Default	Percent of Total Billed Charges	344.84				62.63	344.84
DESTRUCT BENIGN PREMAL LESION 1ST	17000	HCPCS	761	RC		both	355.5	302.18	Medicaid Idaho	Default	Fee Schedule	163.53				62.63	344.84
DESTRUCT BENIGN PREMAL LESION 1ST	17000	HCPCS	761	RC		both	355.5	302.18	Medicare A ID JF	Default	Other	138.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	62.63	344.84
DESTRUCT BENIGN PREMAL LESION 1ST	17000	HCPCS	761	RC		both	355.5	302.18	Medicare B ID JF	Default	Fee Schedule	62.63		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		62.63	344.84
DESTRUCT BENIGN PREMAL LESION 1ST	17000	HCPCS	761	RC		both	355.5	302.18	Regence Group Administrators	Default	Fee Schedule	344.84				62.63	344.84
DESTRUCT BENIGN PREMAL LESION 1ST	17000	HCPCS	761	RC		both	355.5	302.18	SelectHealth	Default	Percent of Total Billed Charges	337.72				62.63	344.84
DESTRUCT BENIGN PREMAL LESION 2-14	17003	HCPCS	761	RC		both	126.5	107.53	Blue Cross of ID	Default	Percent of Total Billed Charges	122.7				6.17	122.7
DESTRUCT BENIGN PREMAL LESION 2-14	17003	HCPCS	761	RC		both	126.5	107.53	Medicaid Idaho	Default	Fee Schedule	58.19				6.17	122.7
DESTRUCT BENIGN PREMAL LESION 2-14	17003	HCPCS	761	RC		both	126.5	107.53	Medicare A ID JF	Default	Other	49.34		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	6.17	122.7
DESTRUCT BENIGN PREMAL LESION 2-14	17003	HCPCS	761	RC		both	126.5	107.53	Medicare B ID JF	Default	Fee Schedule	6.17		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		6.17	122.7
DESTRUCT BENIGN PREMAL LESION 2-14	17003	HCPCS	761	RC		both	126.5	107.53	Regence Group Administrators	Default	Fee Schedule	122.7				6.17	122.7
DESTRUCT BENIGN PREMAL LESION 2-14	17003	HCPCS	761	RC		both	126.5	107.53	SelectHealth	Default	Percent of Total Billed Charges	120.18				6.17	122.7
DESTRUCT BENIGN LESION UP TO 14	17110	HCPCS	761	RC		both	355.5	302.18	Blue Cross of ID	Default	Percent of Total Billed Charges	344.84				104.77	344.84
DESTRUCT BENIGN LESION UP TO 14	17110	HCPCS	761	RC		both	355.5	302.18	Medicaid Idaho	Default	Fee Schedule	163.53				104.77	344.84
DESTRUCT BENIGN LESION UP TO 14	17110	HCPCS	761	RC		both	355.5	302.18	Medicare A ID JF	Default	Other	138.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	104.77	344.84
DESTRUCT BENIGN LESION UP TO 14	17110	HCPCS	761	RC		both	355.5	302.18	Medicare B ID JF	Default	Fee Schedule	104.77		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		104.77	344.84
DESTRUCT BENIGN LESION UP TO 14	17110	HCPCS	761	RC		both	355.5	302.18	Regence Group Administrators	Default	Fee Schedule	344.84				104.77	344.84
DESTRUCT BENIGN LESION UP TO 14	17110	HCPCS	761	RC		both	355.5	302.18	SelectHealth	Default	Percent of Total Billed Charges	337.72				104.77	344.84
DESTRUCT MAL LESION TAL >.5CM	17260	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				92.43	549.99
DESTRUCT MAL LESION TAL >.5CM	17260	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				92.43	549.99
DESTRUCT MAL LESION TAL >.5CM	17260	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	92.43	549.99
DESTRUCT MAL LESION TAL >.5CM	17260	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	92.43		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		92.43	549.99
DESTRUCT MAL LESION TAL >.5CM	17260	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				92.43	549.99
DESTRUCT MAL LESION TAL >.5CM	17260	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				92.43	549.99
DESTRUCT MAL LESION TAL >.5CM	17261	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				137.21	549.99
DESTRUCT MAL LESION TAL >.5CM	17261	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				137.21	549.99
DESTRUCT MAL LESION TAL >.5CM	17261	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	137.21	549.99
DESTRUCT MAL LESION TAL >.5CM	17261	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	137.21		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		137.21	549.99
DESTRUCT MAL LESION TAL >.5CM	17261	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				137.21	549.99
DESTRUCT MAL LESION TAL >.5CM	17261	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				137.21	549.99
DESTRUCT MAL LESION TAL >1.1-2.0CM	17262	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				165.07	549.99
DESTRUCT MAL LESION TAL >1.1-2.0CM	17262	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				165.07	549.99
DESTRUCT MAL LESION TAL >1.1-2.0CM	17262	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	165.07	549.99
DESTRUCT MAL LESION TAL >1.1-2.0CM	17262	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	165.07		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		165.07	549.99
DESTRUCT MAL LESION TAL >1.1-2.0CM	17262	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				165.07	549.99
DESTRUCT MAL LESION TAL >1.1-2.0CM	17262	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				165.07	549.99
DESTRUCT MAL LESION TAL 2.1-3.0CM	17263	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				178.72	549.99
DESTRUCT MAL LESION TAL 2.1-3.0CM	17263	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				178.72	549.99
DESTRUCT MAL LESION TAL 2.1-3.0CM	17263	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	178.72	549.99
DESTRUCT MAL LESION TAL 2.1-3.0CM	17263	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	178.72		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		178.72	549.99
DESTRUCT MAL LESION TAL 2.1-3.0CM	17263	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				178.72	549.99
DESTRUCT MAL LESION TAL 2.1-3.0CM	17263	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				178.72	549.99
DESTRUCT MAL LESION TAL 3.1-4.0CM	17264	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				191.57	549.99
DESTRUCT MAL LESION TAL 3.1-4.0CM	17264	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				191.57	549.99
DESTRUCT MAL LESION TAL 3.1-4.0CM	17264	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	191.57	549.99
DESTRUCT MAL LESION TAL 3.1-4.0CM	17264	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	191.57		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		191.57	549.99
DESTRUCT MAL LESION TAL 3.1-4.0CM	17264	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				191.57	549.99
DESTRUCT MAL LESION TAL 3.1-4.0CM	17264	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				191.57	549.99
DESTRUCT MAL LESION TAL >4.0CM	17266	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				217.89	549.99
DESTRUCT MAL LESION TAL >4.0CM	17266	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				217.89	549.99
DESTRUCT MAL LESION TAL >4.0CM	17266	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	217.89	549.99
DESTRUCT MAL LESION TAL >4.0CM	17266	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	217.89		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		217.89	549.99
DESTRUCT MAL LESION TAL >4.0CM	17266	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				217.89	549.99
DESTRUCT MAL LESION TAL >4.0CM	17266	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				217.89	549.99
DESTRUCT MAL LESION SNHFG <.5CM	17270	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				138.58	549.99
DESTRUCT MAL LESION SNHFG <.5CM	17270	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				138.58	549.99
DESTRUCT MAL LESION SNHFG <.5CM	17270	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	138.58	549.99
DESTRUCT MAL LESION SNHFG <.5CM	17270	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	138.58		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		138.58	549.99
DESTRUCT MAL LESION SNHFG <.5CM	17270	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				138.58	549.99
DESTRUCT MAL LESION SNHFG <.5CM	17270	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				138.58	549.99
DESTRUCT MAL LESION SNHFG .6-1.0CM	17271	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				154.07	549.99
DESTRUCT MAL LESION SNHFG .6-1.0CM	17271	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				154.07	549.99
DESTRUCT MAL LESION SNHFG .6-1.0CM	17271	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	154.07	549.99
DESTRUCT MAL LESION SNHFG .6-1.0CM	17271	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	154.07		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		154.07	549.99
DESTRUCT MAL LESION SNHFG .6-1.0CM	17271	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				154.07	549.99
DESTRUCT MAL LESION SNHFG .6-1.0CM	17271	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				154.07	549.99
DESTRUCT MAL LESION SNHFG 1.1-2.0CM	17272	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				174.73	549.99
DESTRUCT MAL LESION SNHFG 1.1-2.0CM	17272	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				174.73	549.99
DESTRUCT MAL LESION SNHFG 1.1-2.0CM	17272	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	174.73	549.99
DESTRUCT MAL LESION SNHFG 1.1-2.0CM	17272	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	174.73		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		174.73	549.99
DESTRUCT MAL LESION SNHFG 1.1-2.0CM	17272	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				174.73	549.99
DESTRUCT MAL LESION SNHFG 1.1-2.0CM	17272	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				174.73	549.99
DESTRUCT MAL LESION SNHFG 2.1-3.0CM	17273	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				193.88	549.99
DESTRUCT MAL LESION SNHFG 2.1-3.0CM	17273	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				193.88	549.99
DESTRUCT MAL LESION SNHFG 2.1-3.0CM	17273	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	193.88	549.99
DESTRUCT MAL LESION SNHFG 2.1-3.0CM	17273	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	193.88		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		193.88	549.99
DESTRUCT MAL LESION SNHFG 2.1-3.0CM	17273	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				193.88	549.99
DESTRUCT MAL LESION SNHFG 2.1-3.0CM	17273	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				193.88	549.99
DESTRUCT MAL LESION SNHFG 3.1-4.0	17274	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				221.13	549.99
DESTRUCT MAL LESION SNHFG 3.1-4.0	17274	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				221.13	549.99
DESTRUCT MAL LESION SNHFG 3.1-4.0	17274	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	221.13	549.99
DESTRUCT MAL LESION SNHFG 3.1-4.0	17274	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	226.83		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		221.13	549.99
DESTRUCT MAL LESION SNHFG 3.1-4.0	17274	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				221.13	549.99
DESTRUCT MAL LESION SNHFG 3.1-4.0	17274	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				221.13	549.99
DESTRUCT MAL LESION SNHFG >4.0CM	17276	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				221.13	549.99
DESTRUCT MAL LESION SNHFG >4.0CM	17276	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				221.13	549.99
DESTRUCT MAL LESION SNHFG >4.0CM	17276	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	221.13	549.99
DESTRUCT MAL LESION SNHFG >4.0CM	17276	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	263.17		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		221.13	549.99
DESTRUCT MAL LESION SNHFG >4.0CM	17276	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				221.13	549.99
DESTRUCT MAL LESION SNHFG >4.0CM	17276	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				221.13	549.99
DESTRUCT MAL LESION FEENL <.5CM	17280	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				130.26	549.99
DESTRUCT MAL LESION FEENL <.5CM	17280	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				130.26	549.99
DESTRUCT MAL LESION FEENL <.5CM	17280	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	130.26	549.99
DESTRUCT MAL LESION FEENL <.5CM	17280	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	130.26		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		130.26	549.99
DESTRUCT MAL LESION FEENL <.5CM	17280	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				130.26	549.99
DESTRUCT MAL LESION FEENL <.5CM	17280	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				130.26	549.99
DESTRUCT MAL LESION FEENL .6-1.0CM	17281	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				166.72	549.99
DESTRUCT MAL LESION FEENL .6-1.0CM	17281	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				166.72	549.99
DESTRUCT MAL LESION FEENL .6-1.0CM	17281	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	166.72	549.99
DESTRUCT MAL LESION FEENL .6-1.0CM	17281	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	166.72		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		166.72	549.99
DESTRUCT MAL LESION FEENL .6-1.0CM	17281	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				166.72	549.99
DESTRUCT MAL LESION FEENL .6-1.0CM	17281	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				166.72	549.99
DESTRUCT MAL LESION FEENL 1.1-2.0CM	17282	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				190.52	549.99
DESTRUCT MAL LESION FEENL 1.1-2.0CM	17282	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				190.52	549.99
DESTRUCT MAL LESION FEENL 1.1-2.0CM	17282	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	190.52	549.99
DESTRUCT MAL LESION FEENL 1.1-2.0CM	17282	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	190.52		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		190.52	549.99
DESTRUCT MAL LESION FEENL 1.1-2.0CM	17282	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				190.52	549.99
DESTRUCT MAL LESION FEENL 1.1-2.0CM	17282	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				190.52	549.99
DESTRUCT MAL LESION FEENL 2.1-3.0CM	17283	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				221.13	549.99
DESTRUCT MAL LESION FEENL 2.1-3.0CM	17283	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				221.13	549.99
DESTRUCT MAL LESION FEENL 2.1-3.0CM	17283	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	221.13	549.99
DESTRUCT MAL LESION FEENL 2.1-3.0CM	17283	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	225.47		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		221.13	549.99
DESTRUCT MAL LESION FEENL 2.1-3.0CM	17283	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				221.13	549.99
DESTRUCT MAL LESION FEENL 2.1-3.0CM	17283	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				221.13	549.99
DESTRUCT MAL LESION FEENL 3.1-4.0CM	17284	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				221.13	549.99
DESTRUCT MAL LESION FEENL 3.1-4.0CM	17284	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				221.13	549.99
DESTRUCT MAL LESION FEENL 3.1-4.0CM	17284	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	221.13	549.99
DESTRUCT MAL LESION FEENL 3.1-4.0CM	17284	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	256.21		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		221.13	549.99
DESTRUCT MAL LESION FEENL 3.1-4.0CM	17284	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				221.13	549.99
DESTRUCT MAL LESION FEENL 3.1-4.0CM	17284	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				221.13	549.99
DESTRUCT MAL LESION FEENL >4.0CM	17286	HCPCS	761	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				221.13	549.99
DESTRUCT MAL LESION FEENL >4.0CM	17286	HCPCS	761	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				221.13	549.99
DESTRUCT MAL LESION FEENL >4.0CM	17286	HCPCS	761	RC		both	567	481.95	Medicare A ID JF	Default	Other	221.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	221.13	549.99
DESTRUCT MAL LESION FEENL >4.0CM	17286	HCPCS	761	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	329.23		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		221.13	549.99
DESTRUCT MAL LESION FEENL >4.0CM	17286	HCPCS	761	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				221.13	549.99
DESTRUCT MAL LESION FEENL >4.0CM	17286	HCPCS	761	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				221.13	549.99
BONE BIOPSY TROCAR/NEEDLE	20220	HCPCS	761	RC		both	819.5	696.58	Blue Cross of ID	Default	Percent of Total Billed Charges	794.92				212.13	794.92
BONE BIOPSY TROCAR/NEEDLE	20220	HCPCS	761	RC		both	819.5	696.58	Medicaid Idaho	Default	Fee Schedule	376.97				212.13	794.92
BONE BIOPSY TROCAR/NEEDLE	20220	HCPCS	761	RC		both	819.5	696.58	Medicare A ID JF	Default	Other	319.61		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	212.13	794.92
BONE BIOPSY TROCAR/NEEDLE	20220	HCPCS	761	RC		both	819.5	696.58	Medicare B ID JF	Default	Fee Schedule	212.13		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		212.13	794.92
BONE BIOPSY TROCAR/NEEDLE	20220	HCPCS	761	RC		both	819.5	696.58	Regence Group Administrators	Default	Fee Schedule	794.92				212.13	794.92
BONE BIOPSY TROCAR/NEEDLE	20220	HCPCS	761	RC		both	819.5	696.58	SelectHealth	Default	Percent of Total Billed Charges	778.52				212.13	794.92
INJ TRIGGER POINTS	20552	HCPCS	761	RC		both	510	433.5	Blue Cross of ID	Default	Percent of Total Billed Charges	494.7				48.59	494.7
INJ TRIGGER POINTS	20552	HCPCS	761	RC		both	510	433.5	Medicaid Idaho	Default	Fee Schedule	234.6				48.59	494.7
INJ TRIGGER POINTS	20552	HCPCS	761	RC		both	510	433.5	Medicare A ID JF	Default	Other	198.9		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	48.59	494.7
INJ TRIGGER POINTS	20552	HCPCS	761	RC		both	510	433.5	Medicare B ID JF	Default	Fee Schedule	48.59		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		48.59	494.7
INJ TRIGGER POINTS	20552	HCPCS	761	RC		both	510	433.5	Regence Group Administrators	Default	Fee Schedule	494.7				48.59	494.7
INJ TRIGGER POINTS	20552	HCPCS	761	RC		both	510	433.5	SelectHealth	Default	Percent of Total Billed Charges	484.5				48.59	494.7
INJECTION TRIGGER POINT 3 OR MORE MUSCLE	20553	HCPCS	761	RC		both	320.5	272.43	Blue Cross of ID	Default	Percent of Total Billed Charges	310.88				55.97	310.88
INJECTION TRIGGER POINT 3 OR MORE MUSCLE	20553	HCPCS	761	RC		both	320.5	272.43	Medicaid Idaho	Default	Fee Schedule	147.43				55.97	310.88
INJECTION TRIGGER POINT 3 OR MORE MUSCLE	20553	HCPCS	761	RC		both	320.5	272.43	Medicare A ID JF	Default	Other	125		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	55.97	310.88
INJECTION TRIGGER POINT 3 OR MORE MUSCLE	20553	HCPCS	761	RC		both	320.5	272.43	Medicare B ID JF	Default	Fee Schedule	55.97		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		55.97	310.88
INJECTION TRIGGER POINT 3 OR MORE MUSCLE	20553	HCPCS	761	RC		both	320.5	272.43	Regence Group Administrators	Default	Fee Schedule	310.88				55.97	310.88
INJECTION TRIGGER POINT 3 OR MORE MUSCLE	20553	HCPCS	761	RC		both	320.5	272.43	SelectHealth	Default	Percent of Total Billed Charges	304.48				55.97	310.88
DRAIN / INJ JOINT/BURSA W/O US	20605	HCPCS	761	RC		both	188	159.8	Blue Cross of ID	Default	Percent of Total Billed Charges	182.36				50.92	182.36
DRAIN / INJ JOINT/BURSA W/O US	20605	HCPCS	761	RC		both	188	159.8	Medicaid Idaho	Default	Fee Schedule	86.48				50.92	182.36
DRAIN / INJ JOINT/BURSA W/O US	20605	HCPCS	761	RC		both	188	159.8	Medicare A ID JF	Default	Other	73.32		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	50.92	182.36
DRAIN / INJ JOINT/BURSA W/O US	20605	HCPCS	761	RC		both	188	159.8	Medicare B ID JF	Default	Fee Schedule	50.92		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		50.92	182.36
DRAIN / INJ JOINT/BURSA W/O US	20605	HCPCS	761	RC		both	188	159.8	Regence Group Administrators	Default	Fee Schedule	182.36				50.92	182.36
DRAIN / INJ JOINT/BURSA W/O US	20605	HCPCS	761	RC		both	188	159.8	SelectHealth	Default	Percent of Total Billed Charges	178.6				50.92	182.36
ASPIRATION/INJECTION MAJOR JOINT	20610	HCPCS	761	RC		both	730.5	620.93	Blue Cross of ID	Default	Percent of Total Billed Charges	708.58				59.73	708.58
ASPIRATION/INJECTION MAJOR JOINT	20610	HCPCS	761	RC		both	730.5	620.93	Medicaid Idaho	Default	Fee Schedule	336.03				59.73	708.58
ASPIRATION/INJECTION MAJOR JOINT	20610	HCPCS	761	RC		both	730.5	620.93	Medicare A ID JF	Default	Other	284.9		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	59.73	708.58
ASPIRATION/INJECTION MAJOR JOINT	20610	HCPCS	761	RC		both	730.5	620.93	Medicare B ID JF	Default	Fee Schedule	59.73		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		59.73	708.58
ASPIRATION/INJECTION MAJOR JOINT	20610	HCPCS	761	RC		both	730.5	620.93	Regence Group Administrators	Default	Fee Schedule	708.58				59.73	708.58
ASPIRATION/INJECTION MAJOR JOINT	20610	HCPCS	761	RC		both	730.5	620.93	SelectHealth	Default	Percent of Total Billed Charges	693.98				59.73	708.58
REATTACH FINGERTIP	20822	HCPCS	761	RC		both	740.5	629.43	Blue Cross of ID	Default	Percent of Total Billed Charges	718.28				288.8	740.5
REATTACH FINGERTIP	20822	HCPCS	761	RC		both	740.5	629.43	Medicaid Idaho	Default	Fee Schedule	340.63				288.8	740.5
REATTACH FINGERTIP	20822	HCPCS	761	RC		both	740.5	629.43	Medicare A ID JF	Default	Other	288.8		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	288.8	740.5
REATTACH FINGERTIP	20822	HCPCS	761	RC		both	740.5	629.43	Medicare B ID JF	Default	Fee Schedule	740.5		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		288.8	740.5
REATTACH FINGERTIP	20822	HCPCS	761	RC		both	740.5	629.43	Regence Group Administrators	Default	Fee Schedule	718.28				288.8	740.5
REATTACH FINGERTIP	20822	HCPCS	761	RC		both	740.5	629.43	SelectHealth	Default	Percent of Total Billed Charges	703.48				288.8	740.5
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR"	21011	HCPCS	450	RC		both	1125	956.25	Blue Cross of ID	Default	Percent of Total Billed Charges	1091.25				343.11	1091.25
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR"	21011	HCPCS	450	RC		both	1125	956.25	Medicaid Idaho	Default	Fee Schedule	517.5				343.11	1091.25
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR"	21011	HCPCS	450	RC		both	1125	956.25	Medicare A ID JF	Default	Other	438.75		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	343.11	1091.25
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR"	21011	HCPCS	450	RC		both	1125	956.25	Medicare B ID JF	Default	Fee Schedule	343.11		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		343.11	1091.25
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR"	21011	HCPCS	450	RC		both	1125	956.25	Regence Group Administrators	Default	Fee Schedule	1091.25				343.11	1091.25
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR"	21011	HCPCS	450	RC		both	1125	956.25	SelectHealth	Default	Percent of Total Billed Charges	1068.75				343.11	1091.25
"EXC TUMOR S TISS F,S <.5CM"	11400	HCPCS	761	RC		both	1027	872.95	Blue Cross of ID	Default	Percent of Total Billed Charges	996.19				117.94	996.19
"EXC TUMOR S TISS F,S <.5CM"	11400	HCPCS	761	RC		both	1027	872.95	Medicaid Idaho	Default	Fee Schedule	472.42				117.94	996.19
"EXC TUMOR S TISS F,S <.5CM"	11400	HCPCS	761	RC		both	1027	872.95	Medicare A ID JF	Default	Other	400.53		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	117.94	996.19
"EXC TUMOR S TISS F,S <.5CM"	11400	HCPCS	761	RC		both	1027	872.95	Medicare B ID JF	Default	Fee Schedule	117.94		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		117.94	996.19
"EXC TUMOR S TISS F,S <.5CM"	11400	HCPCS	761	RC		both	1027	872.95	Regence Group Administrators	Default	Fee Schedule	996.19				117.94	996.19
"EXC TUMOR S TISS F,S <.5CM"	11400	HCPCS	761	RC		both	1027	872.95	SelectHealth	Default	Percent of Total Billed Charges	975.65				117.94	996.19
CLOSED REDUCTION OFTHE MANDULAR JAW W AN	21485	HCPCS	761	RC		both	1310	1113.5	Blue Cross of ID	Default	Percent of Total Billed Charges	1270.7				510.9	1270.7
CLOSED REDUCTION OFTHE MANDULAR JAW W AN	21485	HCPCS	761	RC		both	1310	1113.5	Medicaid Idaho	Default	Fee Schedule	602.6				510.9	1270.7
CLOSED REDUCTION OFTHE MANDULAR JAW W AN	21485	HCPCS	761	RC		both	1310	1113.5	Medicare A ID JF	Default	Other	510.9		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	510.9	1270.7
CLOSED REDUCTION OFTHE MANDULAR JAW W AN	21485	HCPCS	761	RC		both	1310	1113.5	Medicare B ID JF	Default	Fee Schedule	875.83		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		510.9	1270.7
CLOSED REDUCTION OFTHE MANDULAR JAW W AN	21485	HCPCS	761	RC		both	1310	1113.5	Regence Group Administrators	Default	Fee Schedule	1270.7				510.9	1270.7
CLOSED REDUCTION OFTHE MANDULAR JAW W AN	21485	HCPCS	761	RC		both	1310	1113.5	SelectHealth	Default	Percent of Total Billed Charges	1244.5				510.9	1270.7
BIOPSY NECK/THORAX	21550	HCPCS	761	RC		both	923	784.55	Blue Cross of ID	Default	Percent of Total Billed Charges	895.31				244.86	895.31
BIOPSY NECK/THORAX	21550	HCPCS	761	RC		both	923	784.55	Medicaid Idaho	Default	Fee Schedule	424.58				244.86	895.31
BIOPSY NECK/THORAX	21550	HCPCS	761	RC		both	923	784.55	Medicare A ID JF	Default	Other	359.97		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	244.86	895.31
BIOPSY NECK/THORAX	21550	HCPCS	761	RC		both	923	784.55	Medicare B ID JF	Default	Fee Schedule	244.86		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		244.86	895.31
BIOPSY NECK/THORAX	21550	HCPCS	761	RC		both	923	784.55	Regence Group Administrators	Default	Fee Schedule	895.31				244.86	895.31
BIOPSY NECK/THORAX	21550	HCPCS	761	RC		both	923	784.55	SelectHealth	Default	Percent of Total Billed Charges	876.85				244.86	895.31
EXC NECK LES SC 3 CM/>	21552	HCPCS	761	RC		both	1276	1084.6	Blue Cross of ID	Default	Percent of Total Billed Charges	1237.72				407.26	1237.72
EXC NECK LES SC 3 CM/>	21552	HCPCS	761	RC		both	1276	1084.6	Medicaid Idaho	Default	Fee Schedule	586.96				407.26	1237.72
EXC NECK LES SC 3 CM/>	21552	HCPCS	761	RC		both	1276	1084.6	Medicare A ID JF	Default	Other	497.64		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	407.26	1237.72
EXC NECK LES SC 3 CM/>	21552	HCPCS	761	RC		both	1276	1084.6	Medicare B ID JF	Default	Fee Schedule	407.26		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		407.26	1237.72
EXC NECK LES SC 3 CM/>	21552	HCPCS	761	RC		both	1276	1084.6	Regence Group Administrators	Default	Fee Schedule	1237.72				407.26	1237.72
EXC NECK LES SC 3 CM/>	21552	HCPCS	761	RC		both	1276	1084.6	SelectHealth	Default	Percent of Total Billed Charges	1212.2				407.26	1237.72
EXC TUMOR NECK THOR SUBCUT < 3 C.M.	21555	HCPCS	761	RC		both	1128.5	959.23	Blue Cross of ID	Default	Percent of Total Billed Charges	1094.64				396.63	1094.64
EXC TUMOR NECK THOR SUBCUT < 3 C.M.	21555	HCPCS	761	RC		both	1128.5	959.23	Medicaid Idaho	Default	Fee Schedule	519.11				396.63	1094.64
EXC TUMOR NECK THOR SUBCUT < 3 C.M.	21555	HCPCS	761	RC		both	1128.5	959.23	Medicare A ID JF	Default	Other	440.12		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	396.63	1094.64
EXC TUMOR NECK THOR SUBCUT < 3 C.M.	21555	HCPCS	761	RC		both	1128.5	959.23	Medicare B ID JF	Default	Fee Schedule	396.63		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		396.63	1094.64
EXC TUMOR NECK THOR SUBCUT < 3 C.M.	21555	HCPCS	761	RC		both	1128.5	959.23	Regence Group Administrators	Default	Fee Schedule	1094.64				396.63	1094.64
EXC TUMOR NECK THOR SUBCUT < 3 C.M.	21555	HCPCS	761	RC		both	1128.5	959.23	SelectHealth	Default	Percent of Total Billed Charges	1072.08				396.63	1094.64
EXC TUMOR SOFT TISSUE ABD WALL SUBQ 3 CM	22903	HCPCS	761	RC		both	2762	2347.7	Blue Cross of ID	Default	Percent of Total Billed Charges	2679.14				399.86	2679.14
EXC TUMOR SOFT TISSUE ABD WALL SUBQ 3 CM	22903	HCPCS	761	RC		both	2762	2347.7	Medicaid Idaho	Default	Fee Schedule	1270.52				399.86	2679.14
EXC TUMOR SOFT TISSUE ABD WALL SUBQ 3 CM	22903	HCPCS	761	RC		both	2762	2347.7	Medicare A ID JF	Default	Other	1077.18		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	399.86	2679.14
EXC TUMOR SOFT TISSUE ABD WALL SUBQ 3 CM	22903	HCPCS	761	RC		both	2762	2347.7	Medicare B ID JF	Default	Fee Schedule	399.86		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		399.86	2679.14
EXC TUMOR SOFT TISSUE ABD WALL SUBQ 3 CM	22903	HCPCS	761	RC		both	2762	2347.7	Regence Group Administrators	Default	Fee Schedule	2679.14				399.86	2679.14
EXC TUMOR SOFT TISSUE ABD WALL SUBQ 3 CM	22903	HCPCS	761	RC		both	2762	2347.7	SelectHealth	Default	Percent of Total Billed Charges	2623.9				399.86	2679.14
EXC SOFT TISSUE TUMOR	23075	HCPCS	761	RC		both	541.5	460.28	Blue Cross of ID	Default	Percent of Total Billed Charges	525.26				211.19	525.26
EXC SOFT TISSUE TUMOR	23075	HCPCS	761	RC		both	541.5	460.28	Medicaid Idaho	Default	Fee Schedule	249.09				211.19	525.26
EXC SOFT TISSUE TUMOR	23075	HCPCS	761	RC		both	541.5	460.28	Medicare A ID JF	Default	Other	211.19		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	211.19	525.26
EXC SOFT TISSUE TUMOR	23075	HCPCS	761	RC		both	541.5	460.28	Medicare B ID JF	Default	Fee Schedule	469.96		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		211.19	525.26
EXC SOFT TISSUE TUMOR	23075	HCPCS	761	RC		both	541.5	460.28	Regence Group Administrators	Default	Fee Schedule	525.26				211.19	525.26
EXC SOFT TISSUE TUMOR	23075	HCPCS	761	RC		both	541.5	460.28	SelectHealth	Default	Percent of Total Billed Charges	514.42				211.19	525.26
CLOSE SHOULDER DIS W MANIP W ANES	23655	HCPCS	761	RC		both	1373.5	1167.48	Blue Cross of ID	Default	Percent of Total Billed Charges	1332.3				380.98	1332.3
CLOSE SHOULDER DIS W MANIP W ANES	23655	HCPCS	761	RC		both	1373.5	1167.48	Medicaid Idaho	Default	Fee Schedule	631.81				380.98	1332.3
CLOSE SHOULDER DIS W MANIP W ANES	23655	HCPCS	761	RC		both	1373.5	1167.48	Medicare A ID JF	Default	Other	535.67		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	380.98	1332.3
CLOSE SHOULDER DIS W MANIP W ANES	23655	HCPCS	761	RC		both	1373.5	1167.48	Medicare B ID JF	Default	Fee Schedule	380.98		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		380.98	1332.3
CLOSE SHOULDER DIS W MANIP W ANES	23655	HCPCS	761	RC		both	1373.5	1167.48	Regence Group Administrators	Default	Fee Schedule	1332.3				380.98	1332.3
CLOSE SHOULDER DIS W MANIP W ANES	23655	HCPCS	761	RC		both	1373.5	1167.48	SelectHealth	Default	Percent of Total Billed Charges	1304.82				380.98	1332.3
EXC TUMOR SOFT TISSUE UPPER ARM	24071	HCPCS	761	RC		both	2797	2377.45	Blue Cross of ID	Default	Percent of Total Billed Charges	2713.09				370.63	2713.09
EXC TUMOR SOFT TISSUE UPPER ARM	24071	HCPCS	761	RC		both	2797	2377.45	Medicaid Idaho	Default	Fee Schedule	1286.62				370.63	2713.09
EXC TUMOR SOFT TISSUE UPPER ARM	24071	HCPCS	761	RC		both	2797	2377.45	Medicare A ID JF	Default	Other	1090.83		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	370.63	2713.09
EXC TUMOR SOFT TISSUE UPPER ARM	24071	HCPCS	761	RC		both	2797	2377.45	Medicare B ID JF	Default	Fee Schedule	370.63		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		370.63	2713.09
EXC TUMOR SOFT TISSUE UPPER ARM	24071	HCPCS	761	RC		both	2797	2377.45	Regence Group Administrators	Default	Fee Schedule	2713.09				370.63	2713.09
EXC TUMOR SOFT TISSUE UPPER ARM	24071	HCPCS	761	RC		both	2797	2377.45	SelectHealth	Default	Percent of Total Billed Charges	2657.15				370.63	2713.09
3X3 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	Blue Cross of ID	Default	Percent of Total Billed Charges	522.83				210.21	522.83
3X3 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	Medicaid Idaho	Default	Fee Schedule	247.94				210.21	522.83
3X3 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	Medicare A ID JF	Default	Other	210.21		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	210.21	522.83
3X3 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		210.21	522.83
3X3 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	Regence Group Administrators	Default	Fee Schedule	522.83				210.21	522.83
3X3 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	SelectHealth	Default	Percent of Total Billed Charges	512.05				210.21	522.83
BIOPSY FOREARM/WRIST	25065	HCPCS	761	RC		both	342.5	291.13	Blue Cross of ID	Default	Percent of Total Billed Charges	332.22				133.58	332.22
BIOPSY FOREARM/WRIST	25065	HCPCS	761	RC		both	342.5	291.13	Medicaid Idaho	Default	Fee Schedule	157.55				133.58	332.22
BIOPSY FOREARM/WRIST	25065	HCPCS	761	RC		both	342.5	291.13	Medicare A ID JF	Default	Other	133.58		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	133.58	332.22
BIOPSY FOREARM/WRIST	25065	HCPCS	761	RC		both	342.5	291.13	Medicare B ID JF	Default	Fee Schedule	235.42		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		133.58	332.22
BIOPSY FOREARM/WRIST	25065	HCPCS	761	RC		both	342.5	291.13	Regence Group Administrators	Default	Fee Schedule	332.22				133.58	332.22
BIOPSY FOREARM/WRIST	25065	HCPCS	761	RC		both	342.5	291.13	SelectHealth	Default	Percent of Total Billed Charges	325.38				133.58	332.22
EXC FOREARM LES SC 3 CM/>	25071	HCPCS	761	RC		both	2424	2060.4	Blue Cross of ID	Default	Percent of Total Billed Charges	2351.28				389.41	2351.28
EXC FOREARM LES SC 3 CM/>	25071	HCPCS	761	RC		both	2424	2060.4	Medicaid Idaho	Default	Fee Schedule	1115.04				389.41	2351.28
EXC FOREARM LES SC 3 CM/>	25071	HCPCS	761	RC		both	2424	2060.4	Medicare A ID JF	Default	Other	945.36		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	389.41	2351.28
EXC FOREARM LES SC 3 CM/>	25071	HCPCS	761	RC		both	2424	2060.4	Medicare B ID JF	Default	Fee Schedule	389.41		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		389.41	2351.28
EXC FOREARM LES SC 3 CM/>	25071	HCPCS	761	RC		both	2424	2060.4	Regence Group Administrators	Default	Fee Schedule	2351.28				389.41	2351.28
EXC FOREARM LES SC 3 CM/>	25071	HCPCS	761	RC		both	2424	2060.4	SelectHealth	Default	Percent of Total Billed Charges	2302.8				389.41	2351.28
EXC FOREARM LES SC < 3 CM	25075	HCPCS	761	RC		both	1152.5	979.63	Blue Cross of ID	Default	Percent of Total Billed Charges	1117.92				449.48	1117.92
EXC FOREARM LES SC < 3 CM	25075	HCPCS	761	RC		both	1152.5	979.63	Medicaid Idaho	Default	Fee Schedule	530.15				449.48	1117.92
EXC FOREARM LES SC < 3 CM	25075	HCPCS	761	RC		both	1152.5	979.63	Medicare A ID JF	Default	Other	449.48		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	449.48	1117.92
EXC FOREARM LES SC < 3 CM	25075	HCPCS	761	RC		both	1152.5	979.63	Medicare B ID JF	Default	Fee Schedule	473.39		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		449.48	1117.92
EXC FOREARM LES SC < 3 CM	25075	HCPCS	761	RC		both	1152.5	979.63	Regence Group Administrators	Default	Fee Schedule	1117.92				449.48	1117.92
EXC FOREARM LES SC < 3 CM	25075	HCPCS	761	RC		both	1152.5	979.63	SelectHealth	Default	Percent of Total Billed Charges	1094.88				449.48	1117.92
CLOSED REDUCTION ULNAR SHAFT	25535	HCPCS	761	RC		both	432	367.2	Blue Cross of ID	Default	Percent of Total Billed Charges	419.04				168.48	432
CLOSED REDUCTION ULNAR SHAFT	25535	HCPCS	761	RC		both	432	367.2	Medicaid Idaho	Default	Fee Schedule	198.72				168.48	432
CLOSED REDUCTION ULNAR SHAFT	25535	HCPCS	761	RC		both	432	367.2	Medicare A ID JF	Default	Other	168.48		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	168.48	432
CLOSED REDUCTION ULNAR SHAFT	25535	HCPCS	761	RC		both	432	367.2	Medicare B ID JF	Default	Fee Schedule	432		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		168.48	432
CLOSED REDUCTION ULNAR SHAFT	25535	HCPCS	761	RC		both	432	367.2	Regence Group Administrators	Default	Fee Schedule	419.04				168.48	432
CLOSED REDUCTION ULNAR SHAFT	25535	HCPCS	761	RC		both	432	367.2	SelectHealth	Default	Percent of Total Billed Charges	410.4				168.48	432
EXCISE LESION  TENDON SHEALTH	26160	HCPCS	761	RC		both	342.5	291.13	Blue Cross of ID	Default	Percent of Total Billed Charges	332.22				133.58	342.5
EXCISE LESION  TENDON SHEALTH	26160	HCPCS	761	RC		both	342.5	291.13	Medicaid Idaho	Default	Fee Schedule	157.55				133.58	342.5
EXCISE LESION  TENDON SHEALTH	26160	HCPCS	761	RC		both	342.5	291.13	Medicare A ID JF	Default	Other	133.58		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	133.58	342.5
EXCISE LESION  TENDON SHEALTH	26160	HCPCS	761	RC		both	342.5	291.13	Medicare B ID JF	Default	Fee Schedule	342.5		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		133.58	342.5
EXCISE LESION  TENDON SHEALTH	26160	HCPCS	761	RC		both	342.5	291.13	Regence Group Administrators	Default	Fee Schedule	332.22				133.58	342.5
EXCISE LESION  TENDON SHEALTH	26160	HCPCS	761	RC		both	342.5	291.13	SelectHealth	Default	Percent of Total Billed Charges	325.38				133.58	342.5
REPAIR EXTENSOR TENDON HAND PRIMARY OR S	26410	HCPCS	761	RC		both	1199	1019.15	Blue Cross of ID	Default	Percent of Total Billed Charges	1163.03				467.61	1163.03
REPAIR EXTENSOR TENDON HAND PRIMARY OR S	26410	HCPCS	761	RC		both	1199	1019.15	Medicaid Idaho	Default	Fee Schedule	551.54				467.61	1163.03
REPAIR EXTENSOR TENDON HAND PRIMARY OR S	26410	HCPCS	761	RC		both	1199	1019.15	Medicare A ID JF	Default	Other	467.61		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	467.61	1163.03
REPAIR EXTENSOR TENDON HAND PRIMARY OR S	26410	HCPCS	761	RC		both	1199	1019.15	Medicare B ID JF	Default	Fee Schedule	554.34		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		467.61	1163.03
REPAIR EXTENSOR TENDON HAND PRIMARY OR S	26410	HCPCS	761	RC		both	1199	1019.15	Regence Group Administrators	Default	Fee Schedule	1163.03				467.61	1163.03
REPAIR EXTENSOR TENDON HAND PRIMARY OR S	26410	HCPCS	761	RC		both	1199	1019.15	SelectHealth	Default	Percent of Total Billed Charges	1139.05				467.61	1163.03
CLOSED REDUCT FINGER JOINT	26770	HCPCS	761	RC		both	458	389.3	Blue Cross of ID	Default	Percent of Total Billed Charges	444.26				178.62	444.26
CLOSED REDUCT FINGER JOINT	26770	HCPCS	761	RC		both	458	389.3	Medicaid Idaho	Default	Fee Schedule	210.68				178.62	444.26
CLOSED REDUCT FINGER JOINT	26770	HCPCS	761	RC		both	458	389.3	Medicare A ID JF	Default	Other	178.62		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	178.62	444.26
CLOSED REDUCT FINGER JOINT	26770	HCPCS	761	RC		both	458	389.3	Medicare B ID JF	Default	Fee Schedule	274.86		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		178.62	444.26
CLOSED REDUCT FINGER JOINT	26770	HCPCS	761	RC		both	458	389.3	Regence Group Administrators	Default	Fee Schedule	444.26				178.62	444.26
CLOSED REDUCT FINGER JOINT	26770	HCPCS	761	RC		both	458	389.3	SelectHealth	Default	Percent of Total Billed Charges	435.1				178.62	444.26
SI JOINT INJECTION	27096	HCPCS	761	RC		both	506	430.1	Blue Cross of ID	Default	Percent of Total Billed Charges	490.82				151.46	490.82
SI JOINT INJECTION	27096	HCPCS	761	RC		both	506	430.1	Medicaid Idaho	Default	Fee Schedule	232.76				151.46	490.82
SI JOINT INJECTION	27096	HCPCS	761	RC		both	506	430.1	Medicare A ID JF	Default	Other	197.34		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	151.46	490.82
SI JOINT INJECTION	27096	HCPCS	761	RC		both	506	430.1	Medicare B ID JF	Default	Fee Schedule	151.46		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		151.46	490.82
SI JOINT INJECTION	27096	HCPCS	761	RC		both	506	430.1	Regence Group Administrators	Default	Fee Schedule	490.82				151.46	490.82
SI JOINT INJECTION	27096	HCPCS	761	RC		both	506	430.1	SelectHealth	Default	Percent of Total Billed Charges	480.7				151.46	490.82
EXC TUMOR THIGH KNEE SUBCU	27327	HCPCS	761	RC		both	1380	1173	Blue Cross of ID	Default	Percent of Total Billed Charges	1338.6				456.49	1338.6
EXC TUMOR THIGH KNEE SUBCU	27327	HCPCS	761	RC		both	1380	1173	Medicaid Idaho	Default	Fee Schedule	634.8				456.49	1338.6
EXC TUMOR THIGH KNEE SUBCU	27327	HCPCS	761	RC		both	1380	1173	Medicare A ID JF	Default	Other	538.2		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	456.49	1338.6
EXC TUMOR THIGH KNEE SUBCU	27327	HCPCS	761	RC		both	1380	1173	Medicare B ID JF	Default	Fee Schedule	456.49		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		456.49	1338.6
EXC TUMOR THIGH KNEE SUBCU	27327	HCPCS	761	RC		both	1380	1173	Regence Group Administrators	Default	Fee Schedule	1338.6				456.49	1338.6
EXC TUMOR THIGH KNEE SUBCU	27327	HCPCS	761	RC		both	1380	1173	SelectHealth	Default	Percent of Total Billed Charges	1311				456.49	1338.6
CLOSED REDUCT TIBIAL SHAFT	26770	HCPCS	761	RC		both	444	377.4	Blue Cross of ID	Default	Percent of Total Billed Charges	430.68				173.16	430.68
CLOSED REDUCT TIBIAL SHAFT	26770	HCPCS	761	RC		both	444	377.4	Medicaid Idaho	Default	Fee Schedule	204.24				173.16	430.68
CLOSED REDUCT TIBIAL SHAFT	26770	HCPCS	761	RC		both	444	377.4	Medicare A ID JF	Default	Other	173.16		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	173.16	430.68
CLOSED REDUCT TIBIAL SHAFT	26770	HCPCS	761	RC		both	444	377.4	Medicare B ID JF	Default	Fee Schedule	274.86		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		173.16	430.68
CLOSED REDUCT TIBIAL SHAFT	26770	HCPCS	761	RC		both	444	377.4	Regence Group Administrators	Default	Fee Schedule	430.68				173.16	430.68
CLOSED REDUCT TIBIAL SHAFT	26770	HCPCS	761	RC		both	444	377.4	SelectHealth	Default	Percent of Total Billed Charges	421.8				173.16	430.68
CAST ELBOW TO FINGER	29075	HCPCS	761	RC		both	392	333.2	Blue Cross of ID	Default	Percent of Total Billed Charges	380.24				81.43	380.24
CAST ELBOW TO FINGER	29075	HCPCS	761	RC		both	392	333.2	Medicaid Idaho	Default	Fee Schedule	180.32				81.43	380.24
CAST ELBOW TO FINGER	29075	HCPCS	761	RC		both	392	333.2	Medicare A ID JF	Default	Other	152.88		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	81.43	380.24
CAST ELBOW TO FINGER	29075	HCPCS	761	RC		both	392	333.2	Medicare B ID JF	Default	Fee Schedule	81.43		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		81.43	380.24
CAST ELBOW TO FINGER	29075	HCPCS	761	RC		both	392	333.2	Regence Group Administrators	Default	Fee Schedule	380.24				81.43	380.24
CAST ELBOW TO FINGER	29075	HCPCS	761	RC		both	392	333.2	SelectHealth	Default	Percent of Total Billed Charges	372.4				81.43	380.24
CAST APP WRIST/HAND	29085	HCPCS	761	RC		both	370	314.5	Blue Cross of ID	Default	Percent of Total Billed Charges	358.9				89.45	358.9
CAST APP WRIST/HAND	29085	HCPCS	761	RC		both	370	314.5	Medicaid Idaho	Default	Fee Schedule	170.2				89.45	358.9
CAST APP WRIST/HAND	29085	HCPCS	761	RC		both	370	314.5	Medicare A ID JF	Default	Other	144.3		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	89.45	358.9
CAST APP WRIST/HAND	29085	HCPCS	761	RC		both	370	314.5	Medicare B ID JF	Default	Fee Schedule	89.45		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		89.45	358.9
CAST APP WRIST/HAND	29085	HCPCS	761	RC		both	370	314.5	Regence Group Administrators	Default	Fee Schedule	358.9				89.45	358.9
CAST APP WRIST/HAND	29085	HCPCS	761	RC		both	370	314.5	SelectHealth	Default	Percent of Total Billed Charges	351.5				89.45	358.9
SPLINT APP LONG ARM	29105	HCPCS	761	RC		both	298.5	253.73	Blue Cross of ID	Default	Percent of Total Billed Charges	289.54				76.84	289.54
SPLINT APP LONG ARM	29105	HCPCS	761	RC		both	298.5	253.73	Medicaid Idaho	Default	Fee Schedule	137.31				76.84	289.54
SPLINT APP LONG ARM	29105	HCPCS	761	RC		both	298.5	253.73	Medicare A ID JF	Default	Other	116.42		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	76.84	289.54
SPLINT APP LONG ARM	29105	HCPCS	761	RC		both	298.5	253.73	Medicare B ID JF	Default	Fee Schedule	76.84		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		76.84	289.54
SPLINT APP LONG ARM	29105	HCPCS	761	RC		both	298.5	253.73	Regence Group Administrators	Default	Fee Schedule	289.54				76.84	289.54
SPLINT APP LONG ARM	29105	HCPCS	761	RC		both	298.5	253.73	SelectHealth	Default	Percent of Total Billed Charges	283.58				76.84	289.54
SPLINT APP SHORT ARM	29125	HCPCS	761	RC		both	316	268.6	Blue Cross of ID	Default	Percent of Total Billed Charges	306.52				62.15	306.52
SPLINT APP SHORT ARM	29125	HCPCS	761	RC		both	316	268.6	Medicaid Idaho	Default	Fee Schedule	145.36				62.15	306.52
SPLINT APP SHORT ARM	29125	HCPCS	761	RC		both	316	268.6	Medicare A ID JF	Default	Other	123.24		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	62.15	306.52
SPLINT APP SHORT ARM	29125	HCPCS	761	RC		both	316	268.6	Medicare B ID JF	Default	Fee Schedule	62.15		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		62.15	306.52
SPLINT APP SHORT ARM	29125	HCPCS	761	RC		both	316	268.6	Regence Group Administrators	Default	Fee Schedule	306.52				62.15	306.52
SPLINT APP SHORT ARM	29125	HCPCS	761	RC		both	316	268.6	SelectHealth	Default	Percent of Total Billed Charges	300.2				62.15	306.52
SPLINT FINGER	29130	HCPCS	761	RC		both	167.5	142.38	Blue Cross of ID	Default	Percent of Total Billed Charges	162.48				38.88	162.48
SPLINT FINGER	29130	HCPCS	761	RC		both	167.5	142.38	Medicaid Idaho	Default	Fee Schedule	77.05				38.88	162.48
SPLINT FINGER	29130	HCPCS	761	RC		both	167.5	142.38	Medicare A ID JF	Default	Other	65.33		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	38.88	162.48
SPLINT FINGER	29130	HCPCS	761	RC		both	167.5	142.38	Medicare B ID JF	Default	Fee Schedule	38.88		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		38.88	162.48
SPLINT FINGER	29130	HCPCS	761	RC		both	167.5	142.38	Regence Group Administrators	Default	Fee Schedule	162.48				38.88	162.48
SPLINT FINGER	29130	HCPCS	761	RC		both	167.5	142.38	SelectHealth	Default	Percent of Total Billed Charges	159.12				38.88	162.48
CAST LEG BELOW KNEE	29405	HCPCS	761	RC		both	418.5	355.73	Blue Cross of ID	Default	Percent of Total Billed Charges	405.94				74.87	405.94
CAST LEG BELOW KNEE	29405	HCPCS	761	RC		both	418.5	355.73	Medicaid Idaho	Default	Fee Schedule	192.51				74.87	405.94
CAST LEG BELOW KNEE	29405	HCPCS	761	RC		both	418.5	355.73	Medicare A ID JF	Default	Other	163.22		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	74.87	405.94
CAST LEG BELOW KNEE	29405	HCPCS	761	RC		both	418.5	355.73	Medicare B ID JF	Default	Fee Schedule	74.87		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		74.87	405.94
CAST LEG BELOW KNEE	29405	HCPCS	761	RC		both	418.5	355.73	Regence Group Administrators	Default	Fee Schedule	405.94				74.87	405.94
CAST LEG BELOW KNEE	29405	HCPCS	761	RC		both	418.5	355.73	SelectHealth	Default	Percent of Total Billed Charges	397.58				74.87	405.94
SPLINT APP SH LEG CALF TO FOOT	29515	HCPCS	761	RC		both	298.5	253.73	Blue Cross of ID	Default	Percent of Total Billed Charges	289.54				67.4	289.54
SPLINT APP SH LEG CALF TO FOOT	29515	HCPCS	761	RC		both	298.5	253.73	Medicaid Idaho	Default	Fee Schedule	137.31				67.4	289.54
SPLINT APP SH LEG CALF TO FOOT	29515	HCPCS	761	RC		both	298.5	253.73	Medicare A ID JF	Default	Other	116.42		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	67.4	289.54
SPLINT APP SH LEG CALF TO FOOT	29515	HCPCS	761	RC		both	298.5	253.73	Medicare B ID JF	Default	Fee Schedule	67.4		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		67.4	289.54
SPLINT APP SH LEG CALF TO FOOT	29515	HCPCS	761	RC		both	298.5	253.73	Regence Group Administrators	Default	Fee Schedule	289.54				67.4	289.54
SPLINT APP SH LEG CALF TO FOOT	29515	HCPCS	761	RC		both	298.5	253.73	SelectHealth	Default	Percent of Total Billed Charges	283.58				67.4	289.54
STRAPPING UNNA BOOT	29580	HCPCS	761	RC		both	222.5	189.13	Blue Cross of ID	Default	Percent of Total Billed Charges	215.82				58.67	215.82
STRAPPING UNNA BOOT	29580	HCPCS	761	RC		both	222.5	189.13	Medicaid Idaho	Default	Fee Schedule	102.35				58.67	215.82
STRAPPING UNNA BOOT	29580	HCPCS	761	RC		both	222.5	189.13	Medicare A ID JF	Default	Other	86.78		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	58.67	215.82
STRAPPING UNNA BOOT	29580	HCPCS	761	RC		both	222.5	189.13	Medicare B ID JF	Default	Fee Schedule	58.67		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		58.67	215.82
STRAPPING UNNA BOOT	29580	HCPCS	761	RC		both	222.5	189.13	Regence Group Administrators	Default	Fee Schedule	215.82				58.67	215.82
STRAPPING UNNA BOOT	29580	HCPCS	761	RC		both	222.5	189.13	SelectHealth	Default	Percent of Total Billed Charges	211.38				58.67	215.82
APP COMPRESSION SYSTEM MULTI	29581	HCPCS	761	RC		both	248.5	211.23	Blue Cross of ID	Default	Percent of Total Billed Charges	241.04				81.48	241.04
APP COMPRESSION SYSTEM MULTI	29581	HCPCS	761	RC		both	248.5	211.23	Medicaid Idaho	Default	Fee Schedule	114.31				81.48	241.04
APP COMPRESSION SYSTEM MULTI	29581	HCPCS	761	RC		both	248.5	211.23	Medicare A ID JF	Default	Other	96.92		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	81.48	241.04
APP COMPRESSION SYSTEM MULTI	29581	HCPCS	761	RC		both	248.5	211.23	Medicare B ID JF	Default	Fee Schedule	81.48		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		81.48	241.04
APP COMPRESSION SYSTEM MULTI	29581	HCPCS	761	RC		both	248.5	211.23	Regence Group Administrators	Default	Fee Schedule	241.04				81.48	241.04
APP COMPRESSION SYSTEM MULTI	29581	HCPCS	761	RC		both	248.5	211.23	SelectHealth	Default	Percent of Total Billed Charges	236.08				81.48	241.04
FB REMOVAL NOSE	30300	HCPCS	761	RC		both	297	252.45	Blue Cross of ID	Default	Percent of Total Billed Charges	288.09				115.83	288.09
FB REMOVAL NOSE	30300	HCPCS	761	RC		both	297	252.45	Medicaid Idaho	Default	Fee Schedule	136.62				115.83	288.09
FB REMOVAL NOSE	30300	HCPCS	761	RC		both	297	252.45	Medicare A ID JF	Default	Other	115.83		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	115.83	288.09
FB REMOVAL NOSE	30300	HCPCS	761	RC		both	297	252.45	Medicare B ID JF	Default	Fee Schedule	192.58		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		115.83	288.09
FB REMOVAL NOSE	30300	HCPCS	761	RC		both	297	252.45	Regence Group Administrators	Default	Fee Schedule	288.09				115.83	288.09
FB REMOVAL NOSE	30300	HCPCS	761	RC		both	297	252.45	SelectHealth	Default	Percent of Total Billed Charges	282.15				115.83	288.09
NASAL BLEED SIMPLE	30901	HCPCS	761	RC		both	333	283.05	Blue Cross of ID	Default	Percent of Total Billed Charges	323.01				129.87	323.01
NASAL BLEED SIMPLE	30901	HCPCS	761	RC		both	333	283.05	Medicaid Idaho	Default	Fee Schedule	153.18				129.87	323.01
NASAL BLEED SIMPLE	30901	HCPCS	761	RC		both	333	283.05	Medicare A ID JF	Default	Other	129.87		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	129.87	323.01
NASAL BLEED SIMPLE	30901	HCPCS	761	RC		both	333	283.05	Medicare B ID JF	Default	Fee Schedule	142.6		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		129.87	323.01
NASAL BLEED SIMPLE	30901	HCPCS	761	RC		both	333	283.05	Regence Group Administrators	Default	Fee Schedule	323.01				129.87	323.01
NASAL BLEED SIMPLE	30901	HCPCS	761	RC		both	333	283.05	SelectHealth	Default	Percent of Total Billed Charges	316.35				129.87	323.01
CHEST TUBE INSERTION HEMOTHORAX	32551	HCPCS	761	RC		both	1067.5	907.38	Blue Cross of ID	Default	Percent of Total Billed Charges	1035.48				140.16	1035.48
CHEST TUBE INSERTION HEMOTHORAX	32551	HCPCS	761	RC		both	1067.5	907.38	Medicaid Idaho	Default	Fee Schedule	491.05				140.16	1035.48
CHEST TUBE INSERTION HEMOTHORAX	32551	HCPCS	761	RC		both	1067.5	907.38	Medicare A ID JF	Default	Other	416.33		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	140.16	1035.48
CHEST TUBE INSERTION HEMOTHORAX	32551	HCPCS	761	RC		both	1067.5	907.38	Medicare B ID JF	Default	Fee Schedule	140.16		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		140.16	1035.48
CHEST TUBE INSERTION HEMOTHORAX	32551	HCPCS	761	RC		both	1067.5	907.38	Regence Group Administrators	Default	Fee Schedule	1035.48				140.16	1035.48
CHEST TUBE INSERTION HEMOTHORAX	32551	HCPCS	761	RC		both	1067.5	907.38	SelectHealth	Default	Percent of Total Billed Charges	1014.12				140.16	1035.48
THORACENTESIS W/OUT IMAGINING GUIDANCE	32554	HCPCS	761	RC		both	388	329.8	Blue Cross of ID	Default	Percent of Total Billed Charges	376.36				151.32	376.36
THORACENTESIS W/OUT IMAGINING GUIDANCE	32554	HCPCS	761	RC		both	388	329.8	Medicaid Idaho	Default	Fee Schedule	178.48				151.32	376.36
THORACENTESIS W/OUT IMAGINING GUIDANCE	32554	HCPCS	761	RC		both	388	329.8	Medicare A ID JF	Default	Other	151.32		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	151.32	376.36
THORACENTESIS W/OUT IMAGINING GUIDANCE	32554	HCPCS	761	RC		both	388	329.8	Medicare B ID JF	Default	Fee Schedule	214.33		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		151.32	376.36
THORACENTESIS W/OUT IMAGINING GUIDANCE	32554	HCPCS	761	RC		both	388	329.8	Regence Group Administrators	Default	Fee Schedule	376.36				151.32	376.36
THORACENTESIS W/OUT IMAGINING GUIDANCE	32554	HCPCS	761	RC		both	388	329.8	SelectHealth	Default	Percent of Total Billed Charges	368.6				151.32	376.36
THORACENTESIS W/ IMAGINING GUIDANCE	32555	HCPCS	761	RC		both	489	415.65	Blue Cross of ID	Default	Percent of Total Billed Charges	474.33				190.71	474.33
THORACENTESIS W/ IMAGINING GUIDANCE	32555	HCPCS	761	RC		both	489	415.65	Medicaid Idaho	Default	Fee Schedule	224.94				190.71	474.33
THORACENTESIS W/ IMAGINING GUIDANCE	32555	HCPCS	761	RC		both	489	415.65	Medicare A ID JF	Default	Other	190.71		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	190.71	474.33
THORACENTESIS W/ IMAGINING GUIDANCE	32555	HCPCS	761	RC		both	489	415.65	Medicare B ID JF	Default	Fee Schedule	286.28		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		190.71	474.33
THORACENTESIS W/ IMAGINING GUIDANCE	32555	HCPCS	761	RC		both	489	415.65	Regence Group Administrators	Default	Fee Schedule	474.33				190.71	474.33
THORACENTESIS W/ IMAGINING GUIDANCE	32555	HCPCS	761	RC		both	489	415.65	SelectHealth	Default	Percent of Total Billed Charges	464.55				190.71	474.33
4X4 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	Blue Cross of ID	Default	Percent of Total Billed Charges	522.83				210.21	522.83
4X4 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	Medicaid Idaho	Default	Fee Schedule	247.94				210.21	522.83
4X4 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	Medicare A ID JF	Default	Other	210.21		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	210.21	522.83
4X4 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		210.21	522.83
4X4 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	Regence Group Administrators	Default	Fee Schedule	522.83				210.21	522.83
4X4 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	SelectHealth	Default	Percent of Total Billed Charges	512.05				210.21	522.83
BLOOD ADMIN/UNIT OP	36430	HCPCS	391	RC		both	1047.5	890.38	Blue Cross of ID	Default	Percent of Total Billed Charges	1016.08				37.94	1016.08
BLOOD ADMIN/UNIT OP	36430	HCPCS	391	RC		both	1047.5	890.38	Medicaid Idaho	Default	Fee Schedule	481.85				37.94	1016.08
BLOOD ADMIN/UNIT OP	36430	HCPCS	391	RC		both	1047.5	890.38	Medicare A ID JF	Default	Other	408.53		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	37.94	1016.08
BLOOD ADMIN/UNIT OP	36430	HCPCS	391	RC		both	1047.5	890.38	Medicare B ID JF	Default	Fee Schedule	37.94		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		37.94	1016.08
BLOOD ADMIN/UNIT OP	36430	HCPCS	391	RC		both	1047.5	890.38	Regence Group Administrators	Default	Fee Schedule	1016.08				37.94	1016.08
BLOOD ADMIN/UNIT OP	36430	HCPCS	391	RC		both	1047.5	890.38	SelectHealth	Default	Percent of Total Billed Charges	995.12				37.94	1016.08
CENTRAL LINE INSERTION >5 YEARS	36556	HCPCS	761	RC		both	1178.5	1001.73	Blue Cross of ID	Default	Percent of Total Billed Charges	1143.14				193.87	1143.14
CENTRAL LINE INSERTION >5 YEARS	36556	HCPCS	761	RC		both	1178.5	1001.73	Medicaid Idaho	Default	Fee Schedule	542.11				193.87	1143.14
CENTRAL LINE INSERTION >5 YEARS	36556	HCPCS	761	RC		both	1178.5	1001.73	Medicare A ID JF	Default	Other	459.62		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	193.87	1143.14
CENTRAL LINE INSERTION >5 YEARS	36556	HCPCS	761	RC		both	1178.5	1001.73	Medicare B ID JF	Default	Fee Schedule	193.87		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		193.87	1143.14
CENTRAL LINE INSERTION >5 YEARS	36556	HCPCS	761	RC		both	1178.5	1001.73	Regence Group Administrators	Default	Fee Schedule	1143.14				193.87	1143.14
CENTRAL LINE INSERTION >5 YEARS	36556	HCPCS	761	RC		both	1178.5	1001.73	SelectHealth	Default	Percent of Total Billed Charges	1119.58				193.87	1143.14
PICC LIN INSERTION >5YR	36569	HCPCS	761	RC		both	1214.5	1032.33	Blue Cross of ID	Default	Percent of Total Billed Charges	1178.06				85.83	1178.06
PICC LIN INSERTION >5YR	36569	HCPCS	761	RC		both	1214.5	1032.33	Medicaid Idaho	Default	Fee Schedule	558.67				85.83	1178.06
PICC LIN INSERTION >5YR	36569	HCPCS	761	RC		both	1214.5	1032.33	Medicare A ID JF	Default	Other	473.66		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	85.83	1178.06
PICC LIN INSERTION >5YR	36569	HCPCS	761	RC		both	1214.5	1032.33	Medicare B ID JF	Default	Fee Schedule	85.83		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		85.83	1178.06
PICC LIN INSERTION >5YR	36569	HCPCS	761	RC		both	1214.5	1032.33	Regence Group Administrators	Default	Fee Schedule	1178.06				85.83	1178.06
PICC LIN INSERTION >5YR	36569	HCPCS	761	RC		both	1214.5	1032.33	SelectHealth	Default	Percent of Total Billed Charges	1153.78				85.83	1178.06
BIOPSY LIP	40490	HCPCS	761	RC		both	342.5	291.13	Blue Cross of ID	Default	Percent of Total Billed Charges	332.22				113.03	332.22
BIOPSY LIP	40490	HCPCS	761	RC		both	342.5	291.13	Medicaid Idaho	Default	Fee Schedule	157.55				113.03	332.22
BIOPSY LIP	40490	HCPCS	761	RC		both	342.5	291.13	Medicare A ID JF	Default	Other	133.58		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	113.03	332.22
BIOPSY LIP	40490	HCPCS	761	RC		both	342.5	291.13	Medicare B ID JF	Default	Fee Schedule	113.03		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		113.03	332.22
BIOPSY LIP	40490	HCPCS	761	RC		both	342.5	291.13	Regence Group Administrators	Default	Fee Schedule	332.22				113.03	332.22
BIOPSY LIP	40490	HCPCS	761	RC		both	342.5	291.13	SelectHealth	Default	Percent of Total Billed Charges	325.38				113.03	332.22
EXC SUBMUCOSAL TISS LIP/CHEECK	40812	HCPCS	761	RC		both	355.5	302.18	Blue Cross of ID	Default	Percent of Total Billed Charges	344.84				138.65	344.84
EXC SUBMUCOSAL TISS LIP/CHEECK	40812	HCPCS	761	RC		both	355.5	302.18	Medicaid Idaho	Default	Fee Schedule	163.53				138.65	344.84
EXC SUBMUCOSAL TISS LIP/CHEECK	40812	HCPCS	761	RC		both	355.5	302.18	Medicare A ID JF	Default	Other	138.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	138.65	344.84
EXC SUBMUCOSAL TISS LIP/CHEECK	40812	HCPCS	761	RC		both	355.5	302.18	Medicare B ID JF	Default	Fee Schedule	255.16		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		138.65	344.84
EXC SUBMUCOSAL TISS LIP/CHEECK	40812	HCPCS	761	RC		both	355.5	302.18	Regence Group Administrators	Default	Fee Schedule	344.84				138.65	344.84
EXC SUBMUCOSAL TISS LIP/CHEECK	40812	HCPCS	761	RC		both	355.5	302.18	SelectHealth	Default	Percent of Total Billed Charges	337.72				138.65	344.84
EXC LESION TONGUE WO CLOSURE	11401	HCPCS	761	RC		both	342.5	291.13	Blue Cross of ID	Default	Percent of Total Billed Charges	332.22				133.58	332.22
EXC LESION TONGUE WO CLOSURE	11401	HCPCS	761	RC		both	342.5	291.13	Medicaid Idaho	Default	Fee Schedule	157.55				133.58	332.22
EXC LESION TONGUE WO CLOSURE	11401	HCPCS	761	RC		both	342.5	291.13	Medicare A ID JF	Default	Other	133.58		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	133.58	332.22
EXC LESION TONGUE WO CLOSURE	11401	HCPCS	761	RC		both	342.5	291.13	Medicare B ID JF	Default	Fee Schedule	143.9		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		133.58	332.22
EXC LESION TONGUE WO CLOSURE	11401	HCPCS	761	RC		both	342.5	291.13	Regence Group Administrators	Default	Fee Schedule	332.22				133.58	332.22
EXC LESION TONGUE WO CLOSURE	11401	HCPCS	761	RC		both	342.5	291.13	SelectHealth	Default	Percent of Total Billed Charges	325.38				133.58	332.22
EXC TONGUE @ CLOSURE ANTERIOR 2/3	41112	HCPCS	761	RC		both	342.5	291.13	Blue Cross of ID	Default	Percent of Total Billed Charges	332.22				133.58	332.22
EXC TONGUE @ CLOSURE ANTERIOR 2/3	41112	HCPCS	761	RC		both	342.5	291.13	Medicaid Idaho	Default	Fee Schedule	157.55				133.58	332.22
EXC TONGUE @ CLOSURE ANTERIOR 2/3	41112	HCPCS	761	RC		both	342.5	291.13	Medicare A ID JF	Default	Other	133.58		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	133.58	332.22
EXC TONGUE @ CLOSURE ANTERIOR 2/3	41112	HCPCS	761	RC		both	342.5	291.13	Medicare B ID JF	Default	Fee Schedule	311.91		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		133.58	332.22
EXC TONGUE @ CLOSURE ANTERIOR 2/3	41112	HCPCS	761	RC		both	342.5	291.13	Regence Group Administrators	Default	Fee Schedule	332.22				133.58	332.22
EXC TONGUE @ CLOSURE ANTERIOR 2/3	41112	HCPCS	761	RC		both	342.5	291.13	SelectHealth	Default	Percent of Total Billed Charges	325.38				133.58	332.22
EXC TONGUE LESION W CLOSURE	41113	HCPCS	761	RC		both	897.5	762.88	Blue Cross of ID	Default	Percent of Total Billed Charges	870.58				333.42	870.58
EXC TONGUE LESION W CLOSURE	41113	HCPCS	761	RC		both	897.5	762.88	Medicaid Idaho	Default	Fee Schedule	412.85				333.42	870.58
EXC TONGUE LESION W CLOSURE	41113	HCPCS	761	RC		both	897.5	762.88	Medicare A ID JF	Default	Other	350.03		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	333.42	870.58
EXC TONGUE LESION W CLOSURE	41113	HCPCS	761	RC		both	897.5	762.88	Medicare B ID JF	Default	Fee Schedule	333.42		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		333.42	870.58
EXC TONGUE LESION W CLOSURE	41113	HCPCS	761	RC		both	897.5	762.88	Regence Group Administrators	Default	Fee Schedule	870.58				333.42	870.58
EXC TONGUE LESION W CLOSURE	41113	HCPCS	761	RC		both	897.5	762.88	SelectHealth	Default	Percent of Total Billed Charges	852.62				333.42	870.58
4X6 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	Blue Cross of ID	Default	Percent of Total Billed Charges	522.83				210.21	522.83
4X6 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	Medicaid Idaho	Default	Fee Schedule	247.94				210.21	522.83
4X6 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	Medicare A ID JF	Default	Other	210.21		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	210.21	522.83
4X6 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		210.21	522.83
4X6 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	Regence Group Administrators	Default	Fee Schedule	522.83				210.21	522.83
4X6 CM CYGNUS MATRIX ALLOGRAFT	Q4199	HCPCS	636	RC		both	539	458.15	SelectHealth	Default	Percent of Total Billed Charges	512.05				210.21	522.83
COLONOSOPY W/LESION REMOVAL	45385	HCPCS	761	RC		both	1908.5	1622.23	Blue Cross of ID	Default	Percent of Total Billed Charges	1851.24				416.72	1851.24
COLONOSOPY W/LESION REMOVAL	45385	HCPCS	761	RC		both	1908.5	1622.23	Medicaid Idaho	Default	Fee Schedule	877.91				416.72	1851.24
COLONOSOPY W/LESION REMOVAL	45385	HCPCS	761	RC		both	1908.5	1622.23	Medicare A ID JF	Default	Other	744.32		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	416.72	1851.24
COLONOSOPY W/LESION REMOVAL	45385	HCPCS	761	RC		both	1908.5	1622.23	Medicare B ID JF	Default	Fee Schedule	416.72		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		416.72	1851.24
COLONOSOPY W/LESION REMOVAL	45385	HCPCS	761	RC		both	1908.5	1622.23	Regence Group Administrators	Default	Fee Schedule	1851.24				416.72	1851.24
COLONOSOPY W/LESION REMOVAL	45385	HCPCS	761	RC		both	1908.5	1622.23	SelectHealth	Default	Percent of Total Billed Charges	1813.08				416.72	1851.24
I&D ISCHLORECTA/PERIREC	46040	HCPCS	761	RC		both	768	652.8	Blue Cross of ID	Default	Percent of Total Billed Charges	744.96				299.52	744.96
I&D ISCHLORECTA/PERIREC	46040	HCPCS	761	RC		both	768	652.8	Medicaid Idaho	Default	Fee Schedule	353.28				299.52	744.96
I&D ISCHLORECTA/PERIREC	46040	HCPCS	761	RC		both	768	652.8	Medicare A ID JF	Default	Other	299.52		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	299.52	744.96
I&D ISCHLORECTA/PERIREC	46040	HCPCS	761	RC		both	768	652.8	Medicare B ID JF	Default	Fee Schedule	505.31		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		299.52	744.96
I&D ISCHLORECTA/PERIREC	46040	HCPCS	761	RC		both	768	652.8	Regence Group Administrators	Default	Fee Schedule	744.96				299.52	744.96
I&D ISCHLORECTA/PERIREC	46040	HCPCS	761	RC		both	768	652.8	SelectHealth	Default	Percent of Total Billed Charges	729.6				299.52	744.96
INC THROMBOSED HEMORRHOID EXTERNAL	46083	HCPCS	761	RC		both	477	405.45	Blue Cross of ID	Default	Percent of Total Billed Charges	462.69				186.03	462.69
INC THROMBOSED HEMORRHOID EXTERNAL	46083	HCPCS	761	RC		both	477	405.45	Medicaid Idaho	Default	Fee Schedule	219.42				186.03	462.69
INC THROMBOSED HEMORRHOID EXTERNAL	46083	HCPCS	761	RC		both	477	405.45	Medicare A ID JF	Default	Other	186.03		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	186.03	462.69
INC THROMBOSED HEMORRHOID EXTERNAL	46083	HCPCS	761	RC		both	477	405.45	Medicare B ID JF	Default	Fee Schedule	189.93		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		186.03	462.69
INC THROMBOSED HEMORRHOID EXTERNAL	46083	HCPCS	761	RC		both	477	405.45	Regence Group Administrators	Default	Fee Schedule	462.69				186.03	462.69
INC THROMBOSED HEMORRHOID EXTERNAL	46083	HCPCS	761	RC		both	477	405.45	SelectHealth	Default	Percent of Total Billed Charges	453.15				186.03	462.69
PARACENTESIS W/OUT IMAGING GUIDANCE	49082	HCPCS	761	RC		both	354.5	301.33	Blue Cross of ID	Default	Percent of Total Billed Charges	343.86				138.26	343.86
PARACENTESIS W/OUT IMAGING GUIDANCE	49082	HCPCS	761	RC		both	354.5	301.33	Medicaid Idaho	Default	Fee Schedule	163.07				138.26	343.86
PARACENTESIS W/OUT IMAGING GUIDANCE	49082	HCPCS	761	RC		both	354.5	301.33	Medicare A ID JF	Default	Other	138.26		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	138.26	343.86
PARACENTESIS W/OUT IMAGING GUIDANCE	49082	HCPCS	761	RC		both	354.5	301.33	Medicare B ID JF	Default	Fee Schedule	192.9		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		138.26	343.86
PARACENTESIS W/OUT IMAGING GUIDANCE	49082	HCPCS	761	RC		both	354.5	301.33	Regence Group Administrators	Default	Fee Schedule	343.86				138.26	343.86
PARACENTESIS W/OUT IMAGING GUIDANCE	49082	HCPCS	761	RC		both	354.5	301.33	SelectHealth	Default	Percent of Total Billed Charges	336.78				138.26	343.86
PARACENTESIS W/ IMAGING GUIDANCE	49083	HCPCS	761	RC		both	543.5	461.98	Blue Cross of ID	Default	Percent of Total Billed Charges	527.2				211.97	527.2
PARACENTESIS W/ IMAGING GUIDANCE	49083	HCPCS	761	RC		both	543.5	461.98	Medicaid Idaho	Default	Fee Schedule	250.01				211.97	527.2
PARACENTESIS W/ IMAGING GUIDANCE	49083	HCPCS	761	RC		both	543.5	461.98	Medicare A ID JF	Default	Other	211.97		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	211.97	527.2
PARACENTESIS W/ IMAGING GUIDANCE	49083	HCPCS	761	RC		both	543.5	461.98	Medicare B ID JF	Default	Fee Schedule	266.41		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		211.97	527.2
PARACENTESIS W/ IMAGING GUIDANCE	49083	HCPCS	761	RC		both	543.5	461.98	Regence Group Administrators	Default	Fee Schedule	527.2				211.97	527.2
PARACENTESIS W/ IMAGING GUIDANCE	49083	HCPCS	761	RC		both	543.5	461.98	SelectHealth	Default	Percent of Total Billed Charges	516.32				211.97	527.2
INSERTION CATHETER BLADDER	51701	HCPCS	761	RC		both	253	215.05	Blue Cross of ID	Default	Percent of Total Billed Charges	245.41				40.99	245.41
INSERTION CATHETER BLADDER	51701	HCPCS	761	RC		both	253	215.05	Medicaid Idaho	Default	Fee Schedule	116.38				40.99	245.41
INSERTION CATHETER BLADDER	51701	HCPCS	761	RC		both	253	215.05	Medicare A ID JF	Default	Other	98.67		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	40.99	245.41
INSERTION CATHETER BLADDER	51701	HCPCS	761	RC		both	253	215.05	Medicare B ID JF	Default	Fee Schedule	40.99		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		40.99	245.41
INSERTION CATHETER BLADDER	51701	HCPCS	761	RC		both	253	215.05	Regence Group Administrators	Default	Fee Schedule	245.41				40.99	245.41
INSERTION CATHETER BLADDER	51701	HCPCS	761	RC		both	253	215.05	SelectHealth	Default	Percent of Total Billed Charges	240.35				40.99	245.41
CATH UREATHRA FOLEY	51702	HCPCS	761	RC		both	235.5	200.18	Blue Cross of ID	Default	Percent of Total Billed Charges	228.44				57.16	228.44
CATH UREATHRA FOLEY	51702	HCPCS	761	RC		both	235.5	200.18	Medicaid Idaho	Default	Fee Schedule	108.33				57.16	228.44
CATH UREATHRA FOLEY	51702	HCPCS	761	RC		both	235.5	200.18	Medicare A ID JF	Default	Other	91.85		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	57.16	228.44
CATH UREATHRA FOLEY	51702	HCPCS	761	RC		both	235.5	200.18	Medicare B ID JF	Default	Fee Schedule	57.16		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		57.16	228.44
CATH UREATHRA FOLEY	51702	HCPCS	761	RC		both	235.5	200.18	Regence Group Administrators	Default	Fee Schedule	228.44				57.16	228.44
CATH UREATHRA FOLEY	51702	HCPCS	761	RC		both	235.5	200.18	SelectHealth	Default	Percent of Total Billed Charges	223.72				57.16	228.44
15 MM  CYGNUS MATRIX ALLOGRAFT DISC	Q4199	HCPCS	636	RC		both	539	458.15	Blue Cross of ID	Default	Percent of Total Billed Charges	522.83				210.21	522.83
15 MM  CYGNUS MATRIX ALLOGRAFT DISC	Q4199	HCPCS	636	RC		both	539	458.15	Medicaid Idaho	Default	Fee Schedule	247.94				210.21	522.83
15 MM  CYGNUS MATRIX ALLOGRAFT DISC	Q4199	HCPCS	636	RC		both	539	458.15	Medicare A ID JF	Default	Other	210.21		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	210.21	522.83
15 MM  CYGNUS MATRIX ALLOGRAFT DISC	Q4199	HCPCS	636	RC		both	539	458.15	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		210.21	522.83
15 MM  CYGNUS MATRIX ALLOGRAFT DISC	Q4199	HCPCS	636	RC		both	539	458.15	Regence Group Administrators	Default	Fee Schedule	522.83				210.21	522.83
15 MM  CYGNUS MATRIX ALLOGRAFT DISC	Q4199	HCPCS	636	RC		both	539	458.15	SelectHealth	Default	Percent of Total Billed Charges	512.05				210.21	522.83
VASECTOMY	55250	HCPCS	761	RC		both	718	610.3	Blue Cross of ID	Default	Percent of Total Billed Charges	696.46				280.02	696.46
VASECTOMY	55250	HCPCS	761	RC		both	718	610.3	Medicaid Idaho	Default	Fee Schedule	330.28				280.02	696.46
VASECTOMY	55250	HCPCS	761	RC		both	718	610.3	Medicare A ID JF	Default	Other	280.02		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	280.02	696.46
VASECTOMY	55250	HCPCS	761	RC		both	718	610.3	Medicare B ID JF	Default	Fee Schedule	309.34		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		280.02	696.46
VASECTOMY	55250	HCPCS	761	RC		both	718	610.3	Regence Group Administrators	Default	Fee Schedule	696.46				280.02	696.46
VASECTOMY	55250	HCPCS	761	RC		both	718	610.3	SelectHealth	Default	Percent of Total Billed Charges	682.1				280.02	696.46
COLPOSCOPY CERVIX UPPR/ADJCNT VAGINA W/C	57455	HCPCS	761	RC		both	817	694.45	Blue Cross of ID	Default	Percent of Total Billed Charges	792.49				148.98	792.49
COLPOSCOPY CERVIX UPPR/ADJCNT VAGINA W/C	57455	HCPCS	761	RC		both	817	694.45	Medicaid Idaho	Default	Fee Schedule	375.82				148.98	792.49
COLPOSCOPY CERVIX UPPR/ADJCNT VAGINA W/C	57455	HCPCS	761	RC		both	817	694.45	Medicare A ID JF	Default	Other	318.63		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	148.98	792.49
COLPOSCOPY CERVIX UPPR/ADJCNT VAGINA W/C	57455	HCPCS	761	RC		both	817	694.45	Medicare B ID JF	Default	Fee Schedule	148.98		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		148.98	792.49
COLPOSCOPY CERVIX UPPR/ADJCNT VAGINA W/C	57455	HCPCS	761	RC		both	817	694.45	Regence Group Administrators	Default	Fee Schedule	792.49				148.98	792.49
COLPOSCOPY CERVIX UPPR/ADJCNT VAGINA W/C	57455	HCPCS	761	RC		both	817	694.45	SelectHealth	Default	Percent of Total Billed Charges	776.15				148.98	792.49
REMOVAL IUD	58301	HCPCS	761	RC		both	444.5	377.83	Blue Cross of ID	Default	Percent of Total Billed Charges	431.16				101.41	431.16
REMOVAL IUD	58301	HCPCS	761	RC		both	444.5	377.83	Medicaid Idaho	Default	Fee Schedule	204.47				101.41	431.16
REMOVAL IUD	58301	HCPCS	761	RC		both	444.5	377.83	Medicare A ID JF	Default	Other	173.36		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	101.41	431.16
REMOVAL IUD	58301	HCPCS	761	RC		both	444.5	377.83	Medicare B ID JF	Default	Fee Schedule	101.41		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		101.41	431.16
REMOVAL IUD	58301	HCPCS	761	RC		both	444.5	377.83	Regence Group Administrators	Default	Fee Schedule	431.16				101.41	431.16
REMOVAL IUD	58301	HCPCS	761	RC		both	444.5	377.83	SelectHealth	Default	Percent of Total Billed Charges	422.28				101.41	431.16
AMNIOCENTESIS	59000	HCPCS	761	RC		both	730.5	620.93	Blue Cross of ID	Default	Percent of Total Billed Charges	708.58				105.93	708.58
AMNIOCENTESIS	59000	HCPCS	761	RC		both	730.5	620.93	Medicaid Idaho	Default	Fee Schedule	336.03				105.93	708.58
AMNIOCENTESIS	59000	HCPCS	761	RC		both	730.5	620.93	Medicare A ID JF	Default	Other	284.9		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	105.93	708.58
AMNIOCENTESIS	59000	HCPCS	761	RC		both	730.5	620.93	Medicare B ID JF	Default	Fee Schedule	105.93		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		105.93	708.58
AMNIOCENTESIS	59000	HCPCS	761	RC		both	730.5	620.93	Regence Group Administrators	Default	Fee Schedule	708.58				105.93	708.58
AMNIOCENTESIS	59000	HCPCS	761	RC		both	730.5	620.93	SelectHealth	Default	Percent of Total Billed Charges	693.98				105.93	708.58
STEROID EPIDURAL	360	RC				both	780	663	Blue Cross of ID	Default	Percent of Total Billed Charges	756.6				304.2	756.6
STEROID EPIDURAL	360	RC				both	780	663	Medicaid Idaho	Default	Fee Schedule	358.8				304.2	756.6
STEROID EPIDURAL	360	RC				both	780	663	Medicare A ID JF	Default	Other	304.2		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	304.2	756.6
STEROID EPIDURAL	360	RC				both	780	663	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		304.2	756.6
STEROID EPIDURAL	360	RC				both	780	663	Regence Group Administrators	Default	Fee Schedule	756.6				304.2	756.6
STEROID EPIDURAL	360	RC				both	780	663	SelectHealth	Default	Percent of Total Billed Charges	741				304.2	756.6
LUMBAR PUNCTURE	62270	HCPCS	761	RC		both	841	714.85	Blue Cross of ID	Default	Percent of Total Billed Charges	815.77				132.41	815.77
LUMBAR PUNCTURE	62270	HCPCS	761	RC		both	841	714.85	Medicaid Idaho	Default	Fee Schedule	386.86				132.41	815.77
LUMBAR PUNCTURE	62270	HCPCS	761	RC		both	841	714.85	Medicare A ID JF	Default	Other	327.99		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	132.41	815.77
LUMBAR PUNCTURE	62270	HCPCS	761	RC		both	841	714.85	Medicare B ID JF	Default	Fee Schedule	132.41		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		132.41	815.77
LUMBAR PUNCTURE	62270	HCPCS	761	RC		both	841	714.85	Regence Group Administrators	Default	Fee Schedule	815.77				132.41	815.77
LUMBAR PUNCTURE	62270	HCPCS	761	RC		both	841	714.85	SelectHealth	Default	Percent of Total Billed Charges	798.95				132.41	815.77
LUMBAR PUNCTURE DRAINAGE	62272	HCPCS	761	RC		both	415.5	353.18	Blue Cross of ID	Default	Percent of Total Billed Charges	403.04				162.05	403.04
LUMBAR PUNCTURE DRAINAGE	62272	HCPCS	761	RC		both	415.5	353.18	Medicaid Idaho	Default	Fee Schedule	191.13				162.05	403.04
LUMBAR PUNCTURE DRAINAGE	62272	HCPCS	761	RC		both	415.5	353.18	Medicare A ID JF	Default	Other	162.05		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	162.05	403.04
LUMBAR PUNCTURE DRAINAGE	62272	HCPCS	761	RC		both	415.5	353.18	Medicare B ID JF	Default	Fee Schedule	166.05		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		162.05	403.04
LUMBAR PUNCTURE DRAINAGE	62272	HCPCS	761	RC		both	415.5	353.18	Regence Group Administrators	Default	Fee Schedule	403.04				162.05	403.04
LUMBAR PUNCTURE DRAINAGE	62272	HCPCS	761	RC		both	415.5	353.18	SelectHealth	Default	Percent of Total Billed Charges	394.72				162.05	403.04
STEROID EPIDURAL; BLOOD OR CLOT PATCH	62273	HCPCS	761	RC		both	955	811.75	Blue Cross of ID	Default	Percent of Total Billed Charges	926.35				155.65	926.35
STEROID EPIDURAL; BLOOD OR CLOT PATCH	62273	HCPCS	761	RC		both	955	811.75	Medicaid Idaho	Default	Fee Schedule	439.3				155.65	926.35
STEROID EPIDURAL; BLOOD OR CLOT PATCH	62273	HCPCS	761	RC		both	955	811.75	Medicare A ID JF	Default	Other	372.45		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	155.65	926.35
STEROID EPIDURAL; BLOOD OR CLOT PATCH	62273	HCPCS	761	RC		both	955	811.75	Medicare B ID JF	Default	Fee Schedule	155.65		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		155.65	926.35
STEROID EPIDURAL; BLOOD OR CLOT PATCH	62273	HCPCS	761	RC		both	955	811.75	Regence Group Administrators	Default	Fee Schedule	926.35				155.65	926.35
STEROID EPIDURAL; BLOOD OR CLOT PATCH	62273	HCPCS	761	RC		both	955	811.75	SelectHealth	Default	Percent of Total Billed Charges	907.25				155.65	926.35
EPIDURAL CERV/THORAC	62281	HCPCS	761	RC		both	887.5	754.38	Blue Cross of ID	Default	Percent of Total Billed Charges	860.88				222.65	860.88
EPIDURAL CERV/THORAC	62281	HCPCS	761	RC		both	887.5	754.38	Medicaid Idaho	Default	Fee Schedule	408.25				222.65	860.88
EPIDURAL CERV/THORAC	62281	HCPCS	761	RC		both	887.5	754.38	Medicare A ID JF	Default	Other	346.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	222.65	860.88
EPIDURAL CERV/THORAC	62281	HCPCS	761	RC		both	887.5	754.38	Medicare B ID JF	Default	Fee Schedule	222.65		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		222.65	860.88
EPIDURAL CERV/THORAC	62281	HCPCS	761	RC		both	887.5	754.38	Regence Group Administrators	Default	Fee Schedule	860.88				222.65	860.88
EPIDURAL CERV/THORAC	62281	HCPCS	761	RC		both	887.5	754.38	SelectHealth	Default	Percent of Total Billed Charges	843.12				222.65	860.88
CAUDEL NERVE BLOCK	62326	HCPCS	761	RC		both	730.5	620.93	Blue Cross of ID	Default	Percent of Total Billed Charges	708.58				127.6	708.58
CAUDEL NERVE BLOCK	62326	HCPCS	761	RC		both	730.5	620.93	Medicaid Idaho	Default	Fee Schedule	336.03				127.6	708.58
CAUDEL NERVE BLOCK	62326	HCPCS	761	RC		both	730.5	620.93	Medicare A ID JF	Default	Other	284.9		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	127.6	708.58
CAUDEL NERVE BLOCK	62326	HCPCS	761	RC		both	730.5	620.93	Medicare B ID JF	Default	Fee Schedule	127.6		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		127.6	708.58
CAUDEL NERVE BLOCK	62326	HCPCS	761	RC		both	730.5	620.93	Regence Group Administrators	Default	Fee Schedule	708.58				127.6	708.58
CAUDEL NERVE BLOCK	62326	HCPCS	761	RC		both	730.5	620.93	SelectHealth	Default	Percent of Total Billed Charges	693.98				127.6	708.58
STEROID EPIDURAL	62320	HCPCS	761	RC		both	730.5	620.93	Blue Cross of ID	Default	Percent of Total Billed Charges	708.58				150.5	708.58
STEROID EPIDURAL	62320	HCPCS	761	RC		both	730.5	620.93	Medicaid Idaho	Default	Fee Schedule	336.03				150.5	708.58
STEROID EPIDURAL	62320	HCPCS	761	RC		both	730.5	620.93	Medicare A ID JF	Default	Other	284.9		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	150.5	708.58
STEROID EPIDURAL	62320	HCPCS	761	RC		both	730.5	620.93	Medicare B ID JF	Default	Fee Schedule	150.5		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		150.5	708.58
STEROID EPIDURAL	62320	HCPCS	761	RC		both	730.5	620.93	Regence Group Administrators	Default	Fee Schedule	708.58				150.5	708.58
STEROID EPIDURAL	62320	HCPCS	761	RC		both	730.5	620.93	SelectHealth	Default	Percent of Total Billed Charges	693.98				150.5	708.58
CERVIAL OR THORACIC EPIDURAL W/GUIDANCE	62321	HCPCS	761	RC		both	730.5	620.93	Blue Cross of ID	Default	Percent of Total Billed Charges	708.58				241.62	708.58
CERVIAL OR THORACIC EPIDURAL W/GUIDANCE	62321	HCPCS	761	RC		both	730.5	620.93	Medicaid Idaho	Default	Fee Schedule	336.03				241.62	708.58
CERVIAL OR THORACIC EPIDURAL W/GUIDANCE	62321	HCPCS	761	RC		both	730.5	620.93	Medicare A ID JF	Default	Other	284.9		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	241.62	708.58
CERVIAL OR THORACIC EPIDURAL W/GUIDANCE	62321	HCPCS	761	RC		both	730.5	620.93	Medicare B ID JF	Default	Fee Schedule	241.62		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		241.62	708.58
CERVIAL OR THORACIC EPIDURAL W/GUIDANCE	62321	HCPCS	761	RC		both	730.5	620.93	Regence Group Administrators	Default	Fee Schedule	708.58				241.62	708.58
CERVIAL OR THORACIC EPIDURAL W/GUIDANCE	62321	HCPCS	761	RC		both	730.5	620.93	SelectHealth	Default	Percent of Total Billed Charges	693.98				241.62	708.58
STEROID EPIDURAL	62322	HCPCS	761	RC		both	730.5	620.93	Blue Cross of ID	Default	Percent of Total Billed Charges	708.58				124.93	708.58
STEROID EPIDURAL	62322	HCPCS	761	RC		both	730.5	620.93	Medicaid Idaho	Default	Fee Schedule	336.03				124.93	708.58
STEROID EPIDURAL	62322	HCPCS	761	RC		both	730.5	620.93	Medicare A ID JF	Default	Other	284.9		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	124.93	708.58
STEROID EPIDURAL	62322	HCPCS	761	RC		both	730.5	620.93	Medicare B ID JF	Default	Fee Schedule	124.93		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		124.93	708.58
STEROID EPIDURAL	62322	HCPCS	761	RC		both	730.5	620.93	Regence Group Administrators	Default	Fee Schedule	708.58				124.93	708.58
STEROID EPIDURAL	62322	HCPCS	761	RC		both	730.5	620.93	SelectHealth	Default	Percent of Total Billed Charges	693.98				124.93	708.58
LUMBAR OR SACRAL EPIDURAL WITH GUIDANCE	62323	HCPCS	761	RC		both	723.5	614.98	Blue Cross of ID	Default	Percent of Total Billed Charges	701.8				237.38	701.8
LUMBAR OR SACRAL EPIDURAL WITH GUIDANCE	62323	HCPCS	761	RC		both	723.5	614.98	Medicaid Idaho	Default	Fee Schedule	332.81				237.38	701.8
LUMBAR OR SACRAL EPIDURAL WITH GUIDANCE	62323	HCPCS	761	RC		both	723.5	614.98	Medicare A ID JF	Default	Other	282.17		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	237.38	701.8
LUMBAR OR SACRAL EPIDURAL WITH GUIDANCE	62323	HCPCS	761	RC		both	723.5	614.98	Medicare B ID JF	Default	Fee Schedule	237.38		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		237.38	701.8
LUMBAR OR SACRAL EPIDURAL WITH GUIDANCE	62323	HCPCS	761	RC		both	723.5	614.98	Regence Group Administrators	Default	Fee Schedule	701.8				237.38	701.8
LUMBAR OR SACRAL EPIDURAL WITH GUIDANCE	62323	HCPCS	761	RC		both	723.5	614.98	SelectHealth	Default	Percent of Total Billed Charges	687.32				237.38	701.8
STEROID EPIDURAL	62324	HCPCS	761	RC		both	889	755.65	Blue Cross of ID	Default	Percent of Total Billed Charges	862.33				127.63	862.33
STEROID EPIDURAL	62324	HCPCS	761	RC		both	889	755.65	Medicaid Idaho	Default	Fee Schedule	408.94				127.63	862.33
STEROID EPIDURAL	62324	HCPCS	761	RC		both	889	755.65	Medicare A ID JF	Default	Other	346.71		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	127.63	862.33
STEROID EPIDURAL	62324	HCPCS	761	RC		both	889	755.65	Medicare B ID JF	Default	Fee Schedule	127.63		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		127.63	862.33
STEROID EPIDURAL	62324	HCPCS	761	RC		both	889	755.65	Regence Group Administrators	Default	Fee Schedule	862.33				127.63	862.33
STEROID EPIDURAL	62324	HCPCS	761	RC		both	889	755.65	SelectHealth	Default	Percent of Total Billed Charges	844.55				127.63	862.33
25 MM  CYGNUS MATRIX ALLOGRAFT DISC	Q4199	HCPCS	636	RC		both	539	458.15	Blue Cross of ID	Default	Percent of Total Billed Charges	522.83				210.21	522.83
25 MM  CYGNUS MATRIX ALLOGRAFT DISC	Q4199	HCPCS	636	RC		both	539	458.15	Medicaid Idaho	Default	Fee Schedule	247.94				210.21	522.83
25 MM  CYGNUS MATRIX ALLOGRAFT DISC	Q4199	HCPCS	636	RC		both	539	458.15	Medicare A ID JF	Default	Other	210.21		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	210.21	522.83
25 MM  CYGNUS MATRIX ALLOGRAFT DISC	Q4199	HCPCS	636	RC		both	539	458.15	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		210.21	522.83
25 MM  CYGNUS MATRIX ALLOGRAFT DISC	Q4199	HCPCS	636	RC		both	539	458.15	Regence Group Administrators	Default	Fee Schedule	522.83				210.21	522.83
25 MM  CYGNUS MATRIX ALLOGRAFT DISC	Q4199	HCPCS	636	RC		both	539	458.15	SelectHealth	Default	Percent of Total Billed Charges	512.05				210.21	522.83
OCCIPITAL NERVE BLOCK	64405	HCPCS	761	RC		both	730.5	620.93	Blue Cross of ID	Default	Percent of Total Billed Charges	708.58				68.22	708.58
OCCIPITAL NERVE BLOCK	64405	HCPCS	761	RC		both	730.5	620.93	Medicaid Idaho	Default	Fee Schedule	336.03				68.22	708.58
OCCIPITAL NERVE BLOCK	64405	HCPCS	761	RC		both	730.5	620.93	Medicare A ID JF	Default	Other	284.9		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	68.22	708.58
OCCIPITAL NERVE BLOCK	64405	HCPCS	761	RC		both	730.5	620.93	Medicare B ID JF	Default	Fee Schedule	68.22		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		68.22	708.58
OCCIPITAL NERVE BLOCK	64405	HCPCS	761	RC		both	730.5	620.93	Regence Group Administrators	Default	Fee Schedule	708.58				68.22	708.58
OCCIPITAL NERVE BLOCK	64405	HCPCS	761	RC		both	730.5	620.93	SelectHealth	Default	Percent of Total Billed Charges	693.98				68.22	708.58
NERVE BLOCK	64421	HCPCS	761	RC		both	730.5	620.93	Blue Cross of ID	Default	Percent of Total Billed Charges	708.58				31.01	708.58
NERVE BLOCK	64421	HCPCS	761	RC		both	730.5	620.93	Medicaid Idaho	Default	Fee Schedule	336.03				31.01	708.58
NERVE BLOCK	64421	HCPCS	761	RC		both	730.5	620.93	Medicare A ID JF	Default	Other	284.9		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	31.01	708.58
NERVE BLOCK	64421	HCPCS	761	RC		both	730.5	620.93	Medicare B ID JF	Default	Fee Schedule	31.01		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		31.01	708.58
NERVE BLOCK	64421	HCPCS	761	RC		both	730.5	620.93	Regence Group Administrators	Default	Fee Schedule	708.58				31.01	708.58
NERVE BLOCK	64421	HCPCS	761	RC		both	730.5	620.93	SelectHealth	Default	Percent of Total Billed Charges	693.98				31.01	708.58
NERVE BLOCK ILOINGUNIAL NERVER	64425	HCPCS	761	RC		both	857	728.45	Blue Cross of ID	Default	Percent of Total Billed Charges	831.29				101.92	831.29
NERVE BLOCK ILOINGUNIAL NERVER	64425	HCPCS	761	RC		both	857	728.45	Medicaid Idaho	Default	Fee Schedule	394.22				101.92	831.29
NERVE BLOCK ILOINGUNIAL NERVER	64425	HCPCS	761	RC		both	857	728.45	Medicare A ID JF	Default	Other	334.23		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	101.92	831.29
NERVE BLOCK ILOINGUNIAL NERVER	64425	HCPCS	761	RC		both	857	728.45	Medicare B ID JF	Default	Fee Schedule	101.92		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		101.92	831.29
NERVE BLOCK ILOINGUNIAL NERVER	64425	HCPCS	761	RC		both	857	728.45	Regence Group Administrators	Default	Fee Schedule	831.29				101.92	831.29
NERVE BLOCK ILOINGUNIAL NERVER	64425	HCPCS	761	RC		both	857	728.45	SelectHealth	Default	Percent of Total Billed Charges	814.15				101.92	831.29
"SCIATIC NERVE BLOCK, SINGLE"	64445	HCPCS	761	RC		both	823.5	699.98	Blue Cross of ID	Default	Percent of Total Billed Charges	798.8				146.04	798.8
"SCIATIC NERVE BLOCK, SINGLE"	64445	HCPCS	761	RC		both	823.5	699.98	Medicaid Idaho	Default	Fee Schedule	378.81				146.04	798.8
"SCIATIC NERVE BLOCK, SINGLE"	64445	HCPCS	761	RC		both	823.5	699.98	Medicare A ID JF	Default	Other	321.17		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	146.04	798.8
"SCIATIC NERVE BLOCK, SINGLE"	64445	HCPCS	761	RC		both	823.5	699.98	Medicare B ID JF	Default	Fee Schedule	146.04		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		146.04	798.8
"SCIATIC NERVE BLOCK, SINGLE"	64445	HCPCS	761	RC		both	823.5	699.98	Regence Group Administrators	Default	Fee Schedule	798.8				146.04	798.8
"SCIATIC NERVE BLOCK, SINGLE"	64445	HCPCS	761	RC		both	823.5	699.98	SelectHealth	Default	Percent of Total Billed Charges	782.32				146.04	798.8
NERVE BLOCK/PERPHERAL NERVE	64450	HCPCS	761	RC		both	558.5	474.73	Blue Cross of ID	Default	Percent of Total Billed Charges	541.74				69.27	541.74
NERVE BLOCK/PERPHERAL NERVE	64450	HCPCS	761	RC		both	558.5	474.73	Medicaid Idaho	Default	Fee Schedule	256.91				69.27	541.74
NERVE BLOCK/PERPHERAL NERVE	64450	HCPCS	761	RC		both	558.5	474.73	Medicare A ID JF	Default	Other	217.82		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	69.27	541.74
NERVE BLOCK/PERPHERAL NERVE	64450	HCPCS	761	RC		both	558.5	474.73	Medicare B ID JF	Default	Fee Schedule	69.27		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		69.27	541.74
NERVE BLOCK/PERPHERAL NERVE	64450	HCPCS	761	RC		both	558.5	474.73	Regence Group Administrators	Default	Fee Schedule	541.74				69.27	541.74
NERVE BLOCK/PERPHERAL NERVE	64450	HCPCS	761	RC		both	558.5	474.73	SelectHealth	Default	Percent of Total Billed Charges	530.58				69.27	541.74
STEROID EPIDURAL	64451	HCPCS	510	RC		both	600	510	Blue Cross of ID	Default	Percent of Total Billed Charges	582				209.31	582
STEROID EPIDURAL	64451	HCPCS	510	RC		both	600	510	Medicaid Idaho	Default	Fee Schedule	276				209.31	582
STEROID EPIDURAL	64451	HCPCS	510	RC		both	600	510	Medicare A ID JF	Default	Other	234		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	209.31	582
STEROID EPIDURAL	64451	HCPCS	510	RC		both	600	510	Medicare B ID JF	Default	Fee Schedule	209.31		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		209.31	582
STEROID EPIDURAL	64451	HCPCS	510	RC		both	600	510	Regence Group Administrators	Default	Fee Schedule	582				209.31	582
STEROID EPIDURAL	64451	HCPCS	510	RC		both	600	510	SelectHealth	Default	Percent of Total Billed Charges	570				209.31	582
TRANS EPI C/T EA  ADDL	64480	HCPCS	761	RC		both	600	510	Blue Cross of ID	Default	Percent of Total Billed Charges	582				124.15	582
TRANS EPI C/T EA  ADDL	64480	HCPCS	761	RC		both	600	510	Medicaid Idaho	Default	Fee Schedule	276				124.15	582
TRANS EPI C/T EA  ADDL	64480	HCPCS	761	RC		both	600	510	Medicare A ID JF	Default	Other	234		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	124.15	582
TRANS EPI C/T EA  ADDL	64480	HCPCS	761	RC		both	600	510	Medicare B ID JF	Default	Fee Schedule	124.15		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		124.15	582
TRANS EPI C/T EA  ADDL	64480	HCPCS	761	RC		both	600	510	Regence Group Administrators	Default	Fee Schedule	582				124.15	582
TRANS EPI C/T EA  ADDL	64480	HCPCS	761	RC		both	600	510	SelectHealth	Default	Percent of Total Billed Charges	570				124.15	582
TRANS EPI L/S 1ST LEVEL	64483	HCPCS	761	RC		both	730.5	620.93	Blue Cross of ID	Default	Percent of Total Billed Charges	708.58				226.81	708.58
TRANS EPI L/S 1ST LEVEL	64483	HCPCS	761	RC		both	730.5	620.93	Medicaid Idaho	Default	Fee Schedule	336.03				226.81	708.58
TRANS EPI L/S 1ST LEVEL	64483	HCPCS	761	RC		both	730.5	620.93	Medicare A ID JF	Default	Other	284.9		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	226.81	708.58
TRANS EPI L/S 1ST LEVEL	64483	HCPCS	761	RC		both	730.5	620.93	Medicare B ID JF	Default	Fee Schedule	226.81		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		226.81	708.58
TRANS EPI L/S 1ST LEVEL	64483	HCPCS	761	RC		both	730.5	620.93	Regence Group Administrators	Default	Fee Schedule	708.58				226.81	708.58
TRANS EPI L/S 1ST LEVEL	64483	HCPCS	761	RC		both	730.5	620.93	SelectHealth	Default	Percent of Total Billed Charges	693.98				226.81	708.58
TRANS EPI L/S EACH ADDL	64484	HCPCS	761	RC		both	416	353.6	Blue Cross of ID	Default	Percent of Total Billed Charges	403.52				102.53	403.52
TRANS EPI L/S EACH ADDL	64484	HCPCS	761	RC		both	416	353.6	Medicaid Idaho	Default	Fee Schedule	191.36				102.53	403.52
TRANS EPI L/S EACH ADDL	64484	HCPCS	761	RC		both	416	353.6	Medicare A ID JF	Default	Other	162.24		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	102.53	403.52
TRANS EPI L/S EACH ADDL	64484	HCPCS	761	RC		both	416	353.6	Medicare B ID JF	Default	Fee Schedule	102.53		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		102.53	403.52
TRANS EPI L/S EACH ADDL	64484	HCPCS	761	RC		both	416	353.6	Regence Group Administrators	Default	Fee Schedule	403.52				102.53	403.52
TRANS EPI L/S EACH ADDL	64484	HCPCS	761	RC		both	416	353.6	SelectHealth	Default	Percent of Total Billed Charges	395.2				102.53	403.52
TAP BLOCK UNI BY INFUSION	64487	HCPCS	761	RC		both	592	503.2	Blue Cross of ID	Default	Percent of Total Billed Charges	574.24				195.88	574.24
TAP BLOCK UNI BY INFUSION	64487	HCPCS	761	RC		both	592	503.2	Medicaid Idaho	Default	Fee Schedule	272.32				195.88	574.24
TAP BLOCK UNI BY INFUSION	64487	HCPCS	761	RC		both	592	503.2	Medicare A ID JF	Default	Other	230.88		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	195.88	574.24
TAP BLOCK UNI BY INFUSION	64487	HCPCS	761	RC		both	592	503.2	Medicare B ID JF	Default	Fee Schedule	195.88		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		195.88	574.24
TAP BLOCK UNI BY INFUSION	64487	HCPCS	761	RC		both	592	503.2	Regence Group Administrators	Default	Fee Schedule	574.24				195.88	574.24
TAP BLOCK UNI BY INFUSION	64487	HCPCS	761	RC		both	592	503.2	SelectHealth	Default	Percent of Total Billed Charges	562.4				195.88	574.24
INJ PARA FA JNT C/T 1 LEVEL W GUID	64490	HCPCS	761	RC		both	1380	1173	Blue Cross of ID	Default	Percent of Total Billed Charges	1338.6				177.9	1338.6
INJ PARA FA JNT C/T 1 LEVEL W GUID	64490	HCPCS	761	RC		both	1380	1173	Medicaid Idaho	Default	Fee Schedule	634.8				177.9	1338.6
INJ PARA FA JNT C/T 1 LEVEL W GUID	64490	HCPCS	761	RC		both	1380	1173	Medicare A ID JF	Default	Other	538.2		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	177.9	1338.6
INJ PARA FA JNT C/T 1 LEVEL W GUID	64490	HCPCS	761	RC		both	1380	1173	Medicare B ID JF	Default	Fee Schedule	177.9		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		177.9	1338.6
INJ PARA FA JNT C/T 1 LEVEL W GUID	64490	HCPCS	761	RC		both	1380	1173	Regence Group Administrators	Default	Fee Schedule	1338.6				177.9	1338.6
INJ PARA FA JNT C/T 1 LEVEL W GUID	64490	HCPCS	761	RC		both	1380	1173	SelectHealth	Default	Percent of Total Billed Charges	1311				177.9	1338.6
INJ PARA FA JNT C/T 2ND LEV	64491	HCPCS	761	RC		both	616.5	524.03	Blue Cross of ID	Default	Percent of Total Billed Charges	598				90.02	598
INJ PARA FA JNT C/T 2ND LEV	64491	HCPCS	761	RC		both	616.5	524.03	Medicaid Idaho	Default	Fee Schedule	283.59				90.02	598
INJ PARA FA JNT C/T 2ND LEV	64491	HCPCS	761	RC		both	616.5	524.03	Medicare A ID JF	Default	Other	240.44		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	90.02	598
INJ PARA FA JNT C/T 2ND LEV	64491	HCPCS	761	RC		both	616.5	524.03	Medicare B ID JF	Default	Fee Schedule	90.02		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		90.02	598
INJ PARA FA JNT C/T 2ND LEV	64491	HCPCS	761	RC		both	616.5	524.03	Regence Group Administrators	Default	Fee Schedule	598				90.02	598
INJ PARA FA JNT C/T 2ND LEV	64491	HCPCS	761	RC		both	616.5	524.03	SelectHealth	Default	Percent of Total Billed Charges	585.68				90.02	598
INJ PARA FA JNT C/T 3RD LEVEL	64492	HCPCS	761	RC		both	616.5	524.03	Blue Cross of ID	Default	Percent of Total Billed Charges	598				90.33	598
INJ PARA FA JNT C/T 3RD LEVEL	64492	HCPCS	761	RC		both	616.5	524.03	Medicaid Idaho	Default	Fee Schedule	283.59				90.33	598
INJ PARA FA JNT C/T 3RD LEVEL	64492	HCPCS	761	RC		both	616.5	524.03	Medicare A ID JF	Default	Other	240.44		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	90.33	598
INJ PARA FA JNT C/T 3RD LEVEL	64492	HCPCS	761	RC		both	616.5	524.03	Medicare B ID JF	Default	Fee Schedule	90.33		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		90.33	598
INJ PARA FA JNT C/T 3RD LEVEL	64492	HCPCS	761	RC		both	616.5	524.03	Regence Group Administrators	Default	Fee Schedule	598				90.33	598
INJ PARA FA JNT C/T 3RD LEVEL	64492	HCPCS	761	RC		both	616.5	524.03	SelectHealth	Default	Percent of Total Billed Charges	585.68				90.33	598
INJ PARA  FA JNT L/S 1 LEV W GUID	64493	HCPCS	761	RC		both	772.5	656.63	Blue Cross of ID	Default	Percent of Total Billed Charges	749.32				163.52	749.32
INJ PARA  FA JNT L/S 1 LEV W GUID	64493	HCPCS	761	RC		both	772.5	656.63	Medicaid Idaho	Default	Fee Schedule	355.35				163.52	749.32
INJ PARA  FA JNT L/S 1 LEV W GUID	64493	HCPCS	761	RC		both	772.5	656.63	Medicare A ID JF	Default	Other	301.28		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	163.52	749.32
INJ PARA  FA JNT L/S 1 LEV W GUID	64493	HCPCS	761	RC		both	772.5	656.63	Medicare B ID JF	Default	Fee Schedule	163.52		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		163.52	749.32
INJ PARA  FA JNT L/S 1 LEV W GUID	64493	HCPCS	761	RC		both	772.5	656.63	Regence Group Administrators	Default	Fee Schedule	749.32				163.52	749.32
INJ PARA  FA JNT L/S 1 LEV W GUID	64493	HCPCS	761	RC		both	772.5	656.63	SelectHealth	Default	Percent of Total Billed Charges	733.88				163.52	749.32
INJ PARA FA JNT L/S 2ND LEV	64494	HCPCS	761	RC		both	768.5	653.23	Blue Cross of ID	Default	Percent of Total Billed Charges	745.44				84.09	745.44
INJ PARA FA JNT L/S 2ND LEV	64494	HCPCS	761	RC		both	768.5	653.23	Medicaid Idaho	Default	Fee Schedule	353.51				84.09	745.44
INJ PARA FA JNT L/S 2ND LEV	64494	HCPCS	761	RC		both	768.5	653.23	Medicare A ID JF	Default	Other	299.72		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	84.09	745.44
INJ PARA FA JNT L/S 2ND LEV	64494	HCPCS	761	RC		both	768.5	653.23	Medicare B ID JF	Default	Fee Schedule	84.09		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		84.09	745.44
INJ PARA FA JNT L/S 2ND LEV	64494	HCPCS	761	RC		both	768.5	653.23	Regence Group Administrators	Default	Fee Schedule	745.44				84.09	745.44
INJ PARA FA JNT L/S 2ND LEV	64494	HCPCS	761	RC		both	768.5	653.23	SelectHealth	Default	Percent of Total Billed Charges	730.08				84.09	745.44
INJ PARA FA JNT L/S 3RD LEV	64495	HCPCS	761	RC		both	780	663	Blue Cross of ID	Default	Percent of Total Billed Charges	756.6				84.09	756.6
INJ PARA FA JNT L/S 3RD LEV	64495	HCPCS	761	RC		both	780	663	Medicaid Idaho	Default	Fee Schedule	358.8				84.09	756.6
INJ PARA FA JNT L/S 3RD LEV	64495	HCPCS	761	RC		both	780	663	Medicare A ID JF	Default	Other	304.2		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	84.09	756.6
INJ PARA FA JNT L/S 3RD LEV	64495	HCPCS	761	RC		both	780	663	Medicare B ID JF	Default	Fee Schedule	84.09		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		84.09	756.6
INJ PARA FA JNT L/S 3RD LEV	64495	HCPCS	761	RC		both	780	663	Regence Group Administrators	Default	Fee Schedule	756.6				84.09	756.6
INJ PARA FA JNT L/S 3RD LEV	64495	HCPCS	761	RC		both	780	663	SelectHealth	Default	Percent of Total Billed Charges	741				84.09	756.6
LUMBAR OR THORACIC INJECT PARAVERTBRL	64520	HCPCS	761	RC		both	730.5	620.93	Blue Cross of ID	Default	Percent of Total Billed Charges	708.58				211.36	708.58
LUMBAR OR THORACIC INJECT PARAVERTBRL	64520	HCPCS	761	RC		both	730.5	620.93	Medicaid Idaho	Default	Fee Schedule	336.03				211.36	708.58
LUMBAR OR THORACIC INJECT PARAVERTBRL	64520	HCPCS	761	RC		both	730.5	620.93	Medicare A ID JF	Default	Other	284.9		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	211.36	708.58
LUMBAR OR THORACIC INJECT PARAVERTBRL	64520	HCPCS	761	RC		both	730.5	620.93	Medicare B ID JF	Default	Fee Schedule	211.36		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		211.36	708.58
LUMBAR OR THORACIC INJECT PARAVERTBRL	64520	HCPCS	761	RC		both	730.5	620.93	Regence Group Administrators	Default	Fee Schedule	708.58				211.36	708.58
LUMBAR OR THORACIC INJECT PARAVERTBRL	64520	HCPCS	761	RC		both	730.5	620.93	SelectHealth	Default	Percent of Total Billed Charges	693.98				211.36	708.58
DESTRUCTION OF EXT GEN NERVE	64630	HCPCS	360	RC		both	985	837.25	Blue Cross of ID	Default	Percent of Total Billed Charges	955.45				234.94	955.45
DESTRUCTION OF EXT GEN NERVE	64630	HCPCS	360	RC		both	985	837.25	Medicaid Idaho	Default	Fee Schedule	453.1				234.94	955.45
DESTRUCTION OF EXT GEN NERVE	64630	HCPCS	360	RC		both	985	837.25	Medicare A ID JF	Default	Other	384.15		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	234.94	955.45
DESTRUCTION OF EXT GEN NERVE	64630	HCPCS	360	RC		both	985	837.25	Medicare B ID JF	Default	Fee Schedule	234.94		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		234.94	955.45
DESTRUCTION OF EXT GEN NERVE	64630	HCPCS	360	RC		both	985	837.25	Regence Group Administrators	Default	Fee Schedule	955.45				234.94	955.45
DESTRUCTION OF EXT GEN NERVE	64630	HCPCS	360	RC		both	985	837.25	SelectHealth	Default	Percent of Total Billed Charges	935.75				234.94	955.45
FJN  CERVICAL/THORA SINGLE	64633	HCPCS	360	RC		both	1985	1687.25	Blue Cross of ID	Default	Percent of Total Billed Charges	1925.45				402.87	1925.45
FJN  CERVICAL/THORA SINGLE	64633	HCPCS	360	RC		both	1985	1687.25	Medicaid Idaho	Default	Fee Schedule	913.1				402.87	1925.45
FJN  CERVICAL/THORA SINGLE	64633	HCPCS	360	RC		both	1985	1687.25	Medicare A ID JF	Default	Other	774.15		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	402.87	1925.45
FJN  CERVICAL/THORA SINGLE	64633	HCPCS	360	RC		both	1985	1687.25	Medicare B ID JF	Default	Fee Schedule	402.87		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		402.87	1925.45
FJN  CERVICAL/THORA SINGLE	64633	HCPCS	360	RC		both	1985	1687.25	Regence Group Administrators	Default	Fee Schedule	1925.45				402.87	1925.45
FJN  CERVICAL/THORA SINGLE	64633	HCPCS	360	RC		both	1985	1687.25	SelectHealth	Default	Percent of Total Billed Charges	1885.75				402.87	1925.45
FJN CERVICAL/THORA  SINGLEEACH ADD	64634	HCPCS	360	RC		both	910	773.5	Blue Cross of ID	Default	Percent of Total Billed Charges	882.7				233.93	882.7
FJN CERVICAL/THORA  SINGLEEACH ADD	64634	HCPCS	360	RC		both	910	773.5	Medicaid Idaho	Default	Fee Schedule	418.6				233.93	882.7
FJN CERVICAL/THORA  SINGLEEACH ADD	64634	HCPCS	360	RC		both	910	773.5	Medicare A ID JF	Default	Other	354.9		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	233.93	882.7
FJN CERVICAL/THORA  SINGLEEACH ADD	64634	HCPCS	360	RC		both	910	773.5	Medicare B ID JF	Default	Fee Schedule	233.93		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		233.93	882.7
FJN CERVICAL/THORA  SINGLEEACH ADD	64634	HCPCS	360	RC		both	910	773.5	Regence Group Administrators	Default	Fee Schedule	882.7				233.93	882.7
FJN CERVICAL/THORA  SINGLEEACH ADD	64634	HCPCS	360	RC		both	910	773.5	SelectHealth	Default	Percent of Total Billed Charges	864.5				233.93	882.7
FJN LUMB/SAC SINGLE	64635	HCPCS	360	RC		both	2264.5	1924.83	Blue Cross of ID	Default	Percent of Total Billed Charges	2196.56				406.19	2196.56
FJN LUMB/SAC SINGLE	64635	HCPCS	360	RC		both	2264.5	1924.83	Medicaid Idaho	Default	Fee Schedule	1041.67				406.19	2196.56
FJN LUMB/SAC SINGLE	64635	HCPCS	360	RC		both	2264.5	1924.83	Medicare A ID JF	Default	Other	883.16		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	406.19	2196.56
FJN LUMB/SAC SINGLE	64635	HCPCS	360	RC		both	2264.5	1924.83	Medicare B ID JF	Default	Fee Schedule	406.19		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		406.19	2196.56
FJN LUMB/SAC SINGLE	64635	HCPCS	360	RC		both	2264.5	1924.83	Regence Group Administrators	Default	Fee Schedule	2196.56				406.19	2196.56
FJN LUMB/SAC SINGLE	64635	HCPCS	360	RC		both	2264.5	1924.83	SelectHealth	Default	Percent of Total Billed Charges	2151.28				406.19	2196.56
FJN LUMB/SAC EA  ADDTL	64636	HCPCS	360	RC		both	1218	1035.3	Blue Cross of ID	Default	Percent of Total Billed Charges	1181.46				219.54	1181.46
FJN LUMB/SAC EA  ADDTL	64636	HCPCS	360	RC		both	1218	1035.3	Medicaid Idaho	Default	Fee Schedule	560.28				219.54	1181.46
FJN LUMB/SAC EA  ADDTL	64636	HCPCS	360	RC		both	1218	1035.3	Medicare A ID JF	Default	Other	475.02		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	219.54	1181.46
FJN LUMB/SAC EA  ADDTL	64636	HCPCS	360	RC		both	1218	1035.3	Medicare B ID JF	Default	Fee Schedule	219.54		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		219.54	1181.46
FJN LUMB/SAC EA  ADDTL	64636	HCPCS	360	RC		both	1218	1035.3	Regence Group Administrators	Default	Fee Schedule	1181.46				219.54	1181.46
FJN LUMB/SAC EA  ADDTL	64636	HCPCS	360	RC		both	1218	1035.3	SelectHealth	Default	Percent of Total Billed Charges	1157.1				219.54	1181.46
PERIPHERAL NERVE	64640	HCPCS	761	RC		both	374	317.9	Blue Cross of ID	Default	Percent of Total Billed Charges	362.78				145.86	362.78
PERIPHERAL NERVE	64640	HCPCS	761	RC		both	374	317.9	Medicaid Idaho	Default	Fee Schedule	172.04				145.86	362.78
PERIPHERAL NERVE	64640	HCPCS	761	RC		both	374	317.9	Medicare A ID JF	Default	Other	145.86		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	145.86	362.78
PERIPHERAL NERVE	64640	HCPCS	761	RC		both	374	317.9	Medicare B ID JF	Default	Fee Schedule	228.42		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		145.86	362.78
PERIPHERAL NERVE	64640	HCPCS	761	RC		both	374	317.9	Regence Group Administrators	Default	Fee Schedule	362.78				145.86	362.78
PERIPHERAL NERVE	64640	HCPCS	761	RC		both	374	317.9	SelectHealth	Default	Percent of Total Billed Charges	355.3				145.86	362.78
FB EXTERNAL EYE CONJUNCTIVAL SUPERFICIAL	65205	HCPCS	761	RC		both	245	208.25	Blue Cross of ID	Default	Percent of Total Billed Charges	237.65				26.75	237.65
FB EXTERNAL EYE CONJUNCTIVAL SUPERFICIAL	65205	HCPCS	761	RC		both	245	208.25	Medicaid Idaho	Default	Fee Schedule	112.7				26.75	237.65
FB EXTERNAL EYE CONJUNCTIVAL SUPERFICIAL	65205	HCPCS	761	RC		both	245	208.25	Medicare A ID JF	Default	Other	95.55		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	26.75	237.65
FB EXTERNAL EYE CONJUNCTIVAL SUPERFICIAL	65205	HCPCS	761	RC		both	245	208.25	Medicare B ID JF	Default	Fee Schedule	26.75		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		26.75	237.65
FB EXTERNAL EYE CONJUNCTIVAL SUPERFICIAL	65205	HCPCS	761	RC		both	245	208.25	Regence Group Administrators	Default	Fee Schedule	237.65				26.75	237.65
FB EXTERNAL EYE CONJUNCTIVAL SUPERFICIAL	65205	HCPCS	761	RC		both	245	208.25	SelectHealth	Default	Percent of Total Billed Charges	232.75				26.75	237.65
BIOPSY EYELID	67810	HCPCS	761	RC		both	342.5	291.13	Blue Cross of ID	Default	Percent of Total Billed Charges	332.22				133.58	332.22
BIOPSY EYELID	67810	HCPCS	761	RC		both	342.5	291.13	Medicaid Idaho	Default	Fee Schedule	157.55				133.58	332.22
BIOPSY EYELID	67810	HCPCS	761	RC		both	342.5	291.13	Medicare A ID JF	Default	Other	133.58		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	133.58	332.22
BIOPSY EYELID	67810	HCPCS	761	RC		both	342.5	291.13	Medicare B ID JF	Default	Fee Schedule	168.21		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		133.58	332.22
BIOPSY EYELID	67810	HCPCS	761	RC		both	342.5	291.13	Regence Group Administrators	Default	Fee Schedule	332.22				133.58	332.22
BIOPSY EYELID	67810	HCPCS	761	RC		both	342.5	291.13	SelectHealth	Default	Percent of Total Billed Charges	325.38				133.58	332.22
BIOPSY EXTER EAR	69100	HCPCS	761	RC		both	355.5	302.18	Blue Cross of ID	Default	Percent of Total Billed Charges	344.84				87.89	344.84
BIOPSY EXTER EAR	69100	HCPCS	761	RC		both	355.5	302.18	Medicaid Idaho	Default	Fee Schedule	163.53				87.89	344.84
BIOPSY EXTER EAR	69100	HCPCS	761	RC		both	355.5	302.18	Medicare A ID JF	Default	Other	138.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	87.89	344.84
BIOPSY EXTER EAR	69100	HCPCS	761	RC		both	355.5	302.18	Medicare B ID JF	Default	Fee Schedule	87.89		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		87.89	344.84
BIOPSY EXTER EAR	69100	HCPCS	761	RC		both	355.5	302.18	Regence Group Administrators	Default	Fee Schedule	344.84				87.89	344.84
BIOPSY EXTER EAR	69100	HCPCS	761	RC		both	355.5	302.18	SelectHealth	Default	Percent of Total Billed Charges	337.72				87.89	344.84
EXC EXTER EAR PARTIAL SIMPLE	69110	HCPCS	761	RC		both	577.5	490.88	Blue Cross of ID	Default	Percent of Total Billed Charges	560.18				225.23	560.18
EXC EXTER EAR PARTIAL SIMPLE	69110	HCPCS	761	RC		both	577.5	490.88	Medicaid Idaho	Default	Fee Schedule	265.65				225.23	560.18
EXC EXTER EAR PARTIAL SIMPLE	69110	HCPCS	761	RC		both	577.5	490.88	Medicare A ID JF	Default	Other	225.23		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	225.23	560.18
EXC EXTER EAR PARTIAL SIMPLE	69110	HCPCS	761	RC		both	577.5	490.88	Medicare B ID JF	Default	Fee Schedule	431.36		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		225.23	560.18
EXC EXTER EAR PARTIAL SIMPLE	69110	HCPCS	761	RC		both	577.5	490.88	Regence Group Administrators	Default	Fee Schedule	560.18				225.23	560.18
EXC EXTER EAR PARTIAL SIMPLE	69110	HCPCS	761	RC		both	577.5	490.88	SelectHealth	Default	Percent of Total Billed Charges	548.62				225.23	560.18
TYMPANOSTOMY LOC/TOPICAL ANES UNIL	69433	HCPCS	761	RC		both	484.5	411.83	Blue Cross of ID	Default	Percent of Total Billed Charges	469.96				186.06	469.96
TYMPANOSTOMY LOC/TOPICAL ANES UNIL	69433	HCPCS	761	RC		both	484.5	411.83	Medicaid Idaho	Default	Fee Schedule	222.87				186.06	469.96
TYMPANOSTOMY LOC/TOPICAL ANES UNIL	69433	HCPCS	761	RC		both	484.5	411.83	Medicare A ID JF	Default	Other	188.96		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	186.06	469.96
TYMPANOSTOMY LOC/TOPICAL ANES UNIL	69433	HCPCS	761	RC		both	484.5	411.83	Medicare B ID JF	Default	Fee Schedule	186.06		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		186.06	469.96
TYMPANOSTOMY LOC/TOPICAL ANES UNIL	69433	HCPCS	761	RC		both	484.5	411.83	Regence Group Administrators	Default	Fee Schedule	469.96				186.06	469.96
TYMPANOSTOMY LOC/TOPICAL ANES UNIL	69433	HCPCS	761	RC		both	484.5	411.83	SelectHealth	Default	Percent of Total Billed Charges	460.28				186.06	469.96
IV INFUSION DRUG 1ST HR OUTPATIENT	90774	HCPCS	761	RC		both	482	409.7	Blue Cross of ID	Default	Percent of Total Billed Charges	467.54				187.98	467.54
IV INFUSION DRUG 1ST HR OUTPATIENT	90774	HCPCS	761	RC		both	482	409.7	Medicaid Idaho	Default	Fee Schedule	221.72				187.98	467.54
IV INFUSION DRUG 1ST HR OUTPATIENT	90774	HCPCS	761	RC		both	482	409.7	Medicare A ID JF	Default	Other	187.98		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	187.98	467.54
IV INFUSION DRUG 1ST HR OUTPATIENT	90774	HCPCS	761	RC		both	482	409.7	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		187.98	467.54
IV INFUSION DRUG 1ST HR OUTPATIENT	90774	HCPCS	761	RC		both	482	409.7	Regence Group Administrators	Default	Fee Schedule	467.54				187.98	467.54
IV INFUSION DRUG 1ST HR OUTPATIENT	90774	HCPCS	761	RC		both	482	409.7	SelectHealth	Default	Percent of Total Billed Charges	457.9				187.98	467.54
35 MM  CYGNUS MATRIX ALLOGRAFT DISC	Q4199	HCPCS	636	RC		both	539	458.15	Blue Cross of ID	Default	Percent of Total Billed Charges	522.83				210.21	522.83
35 MM  CYGNUS MATRIX ALLOGRAFT DISC	Q4199	HCPCS	636	RC		both	539	458.15	Medicaid Idaho	Default	Fee Schedule	247.94				210.21	522.83
35 MM  CYGNUS MATRIX ALLOGRAFT DISC	Q4199	HCPCS	636	RC		both	539	458.15	Medicare A ID JF	Default	Other	210.21		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	210.21	522.83
35 MM  CYGNUS MATRIX ALLOGRAFT DISC	Q4199	HCPCS	636	RC		both	539	458.15	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		210.21	522.83
35 MM  CYGNUS MATRIX ALLOGRAFT DISC	Q4199	HCPCS	636	RC		both	539	458.15	Regence Group Administrators	Default	Fee Schedule	522.83				210.21	522.83
35 MM  CYGNUS MATRIX ALLOGRAFT DISC	Q4199	HCPCS	636	RC		both	539	458.15	SelectHealth	Default	Percent of Total Billed Charges	512.05				210.21	522.83
ULTRASOUND GUIDE FOR BIOPSY	76942	HCPCS	402	RC		both	1056	897.6	Blue Cross of ID	Default	Percent of Total Billed Charges	1024.32				51.3	1024.32
ULTRASOUND GUIDE FOR BIOPSY	76942	HCPCS	402	RC		both	1056	897.6	Medicaid Idaho	Default	Fee Schedule	51.3				51.3	1024.32
ULTRASOUND GUIDE FOR BIOPSY	76942	HCPCS	402	RC		both	1056	897.6	Medicare A ID JF	Default	Other	411.84		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	51.3	1024.32
ULTRASOUND GUIDE FOR BIOPSY	76942	HCPCS	402	RC		both	1056	897.6	Medicare B ID JF	Default	Fee Schedule	54.05		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		51.3	1024.32
ULTRASOUND GUIDE FOR BIOPSY	76942	HCPCS	402	RC		both	1056	897.6	Regence Group Administrators	Default	Fee Schedule	1024.32				51.3	1024.32
ULTRASOUND GUIDE FOR BIOPSY	76942	HCPCS	402	RC		both	1056	897.6	SelectHealth	Default	Percent of Total Billed Charges	1003.2				51.3	1024.32
3X3 CM CYGNUS MAX UMBILLICAL CORD	Q4199	HCPCS	636	RC		both	361.5	307.28	Blue Cross of ID	Default	Percent of Total Billed Charges	350.66				140.99	350.66
3X3 CM CYGNUS MAX UMBILLICAL CORD	Q4199	HCPCS	636	RC		both	361.5	307.28	Medicaid Idaho	Default	Fee Schedule	166.29				140.99	350.66
3X3 CM CYGNUS MAX UMBILLICAL CORD	Q4199	HCPCS	636	RC		both	361.5	307.28	Medicare A ID JF	Default	Other	140.99		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	140.99	350.66
3X3 CM CYGNUS MAX UMBILLICAL CORD	Q4199	HCPCS	636	RC		both	361.5	307.28	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		140.99	350.66
3X3 CM CYGNUS MAX UMBILLICAL CORD	Q4199	HCPCS	636	RC		both	361.5	307.28	Regence Group Administrators	Default	Fee Schedule	350.66				140.99	350.66
3X3 CM CYGNUS MAX UMBILLICAL CORD	Q4199	HCPCS	636	RC		both	361.5	307.28	SelectHealth	Default	Percent of Total Billed Charges	343.42				140.99	350.66
TB TEST	86580	HCPCS	761	RC		both	43	36.55	Blue Cross of ID	Default	Percent of Total Billed Charges	41.71				6.6	41.71
TB TEST	86580	HCPCS	761	RC		both	43	36.55	Medicaid Idaho	Default	Fee Schedule	6.6				6.6	41.71
TB TEST	86580	HCPCS	761	RC		both	43	36.55	Medicare A ID JF	Default	Other	16.77		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	6.6	41.71
TB TEST	86580	HCPCS	761	RC		both	43	36.55	Medicare B ID JF	Default	Fee Schedule	9.22		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		6.6	41.71
TB TEST	86580	HCPCS	761	RC		both	43	36.55	Regence Group Administrators	Default	Fee Schedule	41.71				6.6	41.71
TB TEST	86580	HCPCS	761	RC		both	43	36.55	SelectHealth	Default	Percent of Total Billed Charges	40.85				6.6	41.71
INJ-IMMUNIZATION	90471	HCPCS	761	RC		both	52	44.2	Blue Cross of ID	Default	Percent of Total Billed Charges	50.44				19.11	50.44
INJ-IMMUNIZATION	90471	HCPCS	761	RC		both	52	44.2	Medicaid Idaho	Default	Fee Schedule	19.29				19.11	50.44
INJ-IMMUNIZATION	90471	HCPCS	761	RC		both	52	44.2	Medicare A ID JF	Default	Other	20.28		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	19.11	50.44
INJ-IMMUNIZATION	90471	HCPCS	761	RC		both	52	44.2	Medicare B ID JF	Default	Fee Schedule	19.11		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		19.11	50.44
INJ-IMMUNIZATION	90471	HCPCS	761	RC		both	52	44.2	Regence Group Administrators	Default	Fee Schedule	50.44				19.11	50.44
INJ-IMMUNIZATION	90471	HCPCS	761	RC		both	52	44.2	SelectHealth	Default	Percent of Total Billed Charges	49.4				19.11	50.44
INJ/IMMUNIZATION EA ADD	90472	HCPCS	761	RC		both	57.5	48.88	Blue Cross of ID	Default	Percent of Total Billed Charges	55.78				13.61	55.78
INJ/IMMUNIZATION EA ADD	90472	HCPCS	761	RC		both	57.5	48.88	Medicaid Idaho	Default	Fee Schedule	26.45				13.61	55.78
INJ/IMMUNIZATION EA ADD	90472	HCPCS	761	RC		both	57.5	48.88	Medicare A ID JF	Default	Other	22.43		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	13.61	55.78
INJ/IMMUNIZATION EA ADD	90472	HCPCS	761	RC		both	57.5	48.88	Medicare B ID JF	Default	Fee Schedule	13.61		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		13.61	55.78
INJ/IMMUNIZATION EA ADD	90472	HCPCS	761	RC		both	57.5	48.88	Regence Group Administrators	Default	Fee Schedule	55.78				13.61	55.78
INJ/IMMUNIZATION EA ADD	90472	HCPCS	761	RC		both	57.5	48.88	SelectHealth	Default	Percent of Total Billed Charges	54.62				13.61	55.78
TETNUS 7 YR OR OLDER	90471	HCPCS	761	RC		both	302.5	257.13	Blue Cross of ID	Default	Percent of Total Billed Charges	293.42				19.11	293.42
TETNUS 7 YR OR OLDER	90471	HCPCS	761	RC		both	302.5	257.13	Medicaid Idaho	Default	Fee Schedule	19.29				19.11	293.42
TETNUS 7 YR OR OLDER	90471	HCPCS	761	RC		both	302.5	257.13	Medicare A ID JF	Default	Other	117.98		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	19.11	293.42
TETNUS 7 YR OR OLDER	90471	HCPCS	761	RC		both	302.5	257.13	Medicare B ID JF	Default	Fee Schedule	19.11		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		19.11	293.42
TETNUS 7 YR OR OLDER	90471	HCPCS	761	RC		both	302.5	257.13	Regence Group Administrators	Default	Fee Schedule	293.42				19.11	293.42
TETNUS 7 YR OR OLDER	90471	HCPCS	761	RC		both	302.5	257.13	SelectHealth	Default	Percent of Total Billed Charges	287.38				19.11	293.42
IV HYDRATION INITIAL 1ST HR	96360	HCPCS	761	RC		both	510	433.5	Blue Cross of ID	Default	Percent of Total Billed Charges	494.7				29.69	494.7
IV HYDRATION INITIAL 1ST HR	96360	HCPCS	761	RC		both	510	433.5	Medicaid Idaho	Default	Fee Schedule	234.6				29.69	494.7
IV HYDRATION INITIAL 1ST HR	96360	HCPCS	761	RC		both	510	433.5	Medicare A ID JF	Default	Other	198.9		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	29.69	494.7
IV HYDRATION INITIAL 1ST HR	96360	HCPCS	761	RC		both	510	433.5	Medicare B ID JF	Default	Fee Schedule	29.69		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		29.69	494.7
IV HYDRATION INITIAL 1ST HR	96360	HCPCS	761	RC		both	510	433.5	Regence Group Administrators	Default	Fee Schedule	494.7				29.69	494.7
IV HYDRATION INITIAL 1ST HR	96360	HCPCS	761	RC		both	510	433.5	SelectHealth	Default	Percent of Total Billed Charges	484.5				29.69	494.7
IV HYDRATION ADDL UP TO 8HR	96361	HCPCS	761	RC		both	124.5	105.83	Blue Cross of ID	Default	Percent of Total Billed Charges	120.76				11.31	120.76
IV HYDRATION ADDL UP TO 8HR	96361	HCPCS	761	RC		both	124.5	105.83	Medicaid Idaho	Default	Fee Schedule	57.27				11.31	120.76
IV HYDRATION ADDL UP TO 8HR	96361	HCPCS	761	RC		both	124.5	105.83	Medicare A ID JF	Default	Other	48.56		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	11.31	120.76
IV HYDRATION ADDL UP TO 8HR	96361	HCPCS	761	RC		both	124.5	105.83	Medicare B ID JF	Default	Fee Schedule	11.31		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		11.31	120.76
IV HYDRATION ADDL UP TO 8HR	96361	HCPCS	761	RC		both	124.5	105.83	Regence Group Administrators	Default	Fee Schedule	120.76				11.31	120.76
IV HYDRATION ADDL UP TO 8HR	96361	HCPCS	761	RC		both	124.5	105.83	SelectHealth	Default	Percent of Total Billed Charges	118.28				11.31	120.76
IV INFUSION DRUG  1ST HR	96365	HCPCS	761	RC		both	444	377.4	Blue Cross of ID	Default	Percent of Total Billed Charges	430.68				56.87	430.68
IV INFUSION DRUG  1ST HR	96365	HCPCS	761	RC		both	444	377.4	Medicaid Idaho	Default	Fee Schedule	204.24				56.87	430.68
IV INFUSION DRUG  1ST HR	96365	HCPCS	761	RC		both	444	377.4	Medicare A ID JF	Default	Other	173.16		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	56.87	430.68
IV INFUSION DRUG  1ST HR	96365	HCPCS	761	RC		both	444	377.4	Medicare B ID JF	Default	Fee Schedule	56.87		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		56.87	430.68
IV INFUSION DRUG  1ST HR	96365	HCPCS	761	RC		both	444	377.4	Regence Group Administrators	Default	Fee Schedule	430.68				56.87	430.68
IV INFUSION DRUG  1ST HR	96365	HCPCS	761	RC		both	444	377.4	SelectHealth	Default	Percent of Total Billed Charges	421.8				56.87	430.68
IV THERAPY ADD HR 8 MAX	96366	HCPCS	761	RC		both	111	94.35	Blue Cross of ID	Default	Percent of Total Billed Charges	107.67				18.84	107.67
IV THERAPY ADD HR 8 MAX	96366	HCPCS	761	RC		both	111	94.35	Medicaid Idaho	Default	Fee Schedule	51.06				18.84	107.67
IV THERAPY ADD HR 8 MAX	96366	HCPCS	761	RC		both	111	94.35	Medicare A ID JF	Default	Other	43.29		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	18.84	107.67
IV THERAPY ADD HR 8 MAX	96366	HCPCS	761	RC		both	111	94.35	Medicare B ID JF	Default	Fee Schedule	18.84		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		18.84	107.67
IV THERAPY ADD HR 8 MAX	96366	HCPCS	761	RC		both	111	94.35	Regence Group Administrators	Default	Fee Schedule	107.67				18.84	107.67
IV THERAPY ADD HR 8 MAX	96366	HCPCS	761	RC		both	111	94.35	SelectHealth	Default	Percent of Total Billed Charges	105.45				18.84	107.67
SEQUENTIAL INFUSION ADDL HR	96367	HCPCS	761	RC		both	265.5	225.68	Blue Cross of ID	Default	Percent of Total Billed Charges	257.54				26.12	257.54
SEQUENTIAL INFUSION ADDL HR	96367	HCPCS	761	RC		both	265.5	225.68	Medicaid Idaho	Default	Fee Schedule	122.13				26.12	257.54
SEQUENTIAL INFUSION ADDL HR	96367	HCPCS	761	RC		both	265.5	225.68	Medicare A ID JF	Default	Other	103.55		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	26.12	257.54
SEQUENTIAL INFUSION ADDL HR	96367	HCPCS	761	RC		both	265.5	225.68	Medicare B ID JF	Default	Fee Schedule	26.12		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		26.12	257.54
SEQUENTIAL INFUSION ADDL HR	96367	HCPCS	761	RC		both	265.5	225.68	Regence Group Administrators	Default	Fee Schedule	257.54				26.12	257.54
SEQUENTIAL INFUSION ADDL HR	96367	HCPCS	761	RC		both	265.5	225.68	SelectHealth	Default	Percent of Total Billed Charges	252.22				26.12	257.54
IV INFUS ADD SEQUENTIAL	96368	HCPCS	761	RC		both	115	97.75	Blue Cross of ID	Default	Percent of Total Billed Charges	111.55				18.2	111.55
IV INFUS ADD SEQUENTIAL	96368	HCPCS	761	RC		both	115	97.75	Medicaid Idaho	Default	Fee Schedule	52.9				18.2	111.55
IV INFUS ADD SEQUENTIAL	96368	HCPCS	761	RC		both	115	97.75	Medicare A ID JF	Default	Other	44.85		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	18.2	111.55
IV INFUS ADD SEQUENTIAL	96368	HCPCS	761	RC		both	115	97.75	Medicare B ID JF	Default	Fee Schedule	18.2		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		18.2	111.55
IV INFUS ADD SEQUENTIAL	96368	HCPCS	761	RC		both	115	97.75	Regence Group Administrators	Default	Fee Schedule	111.55				18.2	111.55
IV INFUS ADD SEQUENTIAL	96368	HCPCS	761	RC		both	115	97.75	SelectHealth	Default	Percent of Total Billed Charges	109.25				18.2	111.55
SQ/IM INJECTION	96372	HCPCS	761	RC		both	73.5	62.48	Blue Cross of ID	Default	Percent of Total Billed Charges	71.3				13.37	71.3
SQ/IM INJECTION	96372	HCPCS	761	RC		both	73.5	62.48	Medicaid Idaho	Default	Fee Schedule	33.81				13.37	71.3
SQ/IM INJECTION	96372	HCPCS	761	RC		both	73.5	62.48	Medicare A ID JF	Default	Other	28.67		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	13.37	71.3
SQ/IM INJECTION	96372	HCPCS	761	RC		both	73.5	62.48	Medicare B ID JF	Default	Fee Schedule	13.37		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		13.37	71.3
SQ/IM INJECTION	96372	HCPCS	761	RC		both	73.5	62.48	Regence Group Administrators	Default	Fee Schedule	71.3				13.37	71.3
SQ/IM INJECTION	96372	HCPCS	761	RC		both	73.5	62.48	SelectHealth	Default	Percent of Total Billed Charges	69.82				13.37	71.3
INJ IV PUSH	96374	HCPCS	761	RC		both	232.5	197.63	Blue Cross of ID	Default	Percent of Total Billed Charges	225.52				33.5	225.52
INJ IV PUSH	96374	HCPCS	761	RC		both	232.5	197.63	Medicaid Idaho	Default	Fee Schedule	106.95				33.5	225.52
INJ IV PUSH	96374	HCPCS	761	RC		both	232.5	197.63	Medicare A ID JF	Default	Other	90.68		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	33.5	225.52
INJ IV PUSH	96374	HCPCS	761	RC		both	232.5	197.63	Medicare B ID JF	Default	Fee Schedule	33.5		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		33.5	225.52
INJ IV PUSH	96374	HCPCS	761	RC		both	232.5	197.63	Regence Group Administrators	Default	Fee Schedule	225.52				33.5	225.52
INJ IV PUSH	96374	HCPCS	761	RC		both	232.5	197.63	SelectHealth	Default	Percent of Total Billed Charges	220.88				33.5	225.52
IV PUSH EA ADD	96375	HCPCS	761	RC		both	244	207.4	Blue Cross of ID	Default	Percent of Total Billed Charges	236.68				14.06	236.68
IV PUSH EA ADD	96375	HCPCS	761	RC		both	244	207.4	Medicaid Idaho	Default	Fee Schedule	112.24				14.06	236.68
IV PUSH EA ADD	96375	HCPCS	761	RC		both	244	207.4	Medicare A ID JF	Default	Other	95.16		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	14.06	236.68
IV PUSH EA ADD	96375	HCPCS	761	RC		both	244	207.4	Medicare B ID JF	Default	Fee Schedule	14.06		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		14.06	236.68
IV PUSH EA ADD	96375	HCPCS	761	RC		both	244	207.4	Regence Group Administrators	Default	Fee Schedule	236.68				14.06	236.68
IV PUSH EA ADD	96375	HCPCS	761	RC		both	244	207.4	SelectHealth	Default	Percent of Total Billed Charges	231.8				14.06	236.68
CARDIOVERSION	92960	HCPCS	761	RC		both	895.5	761.18	Blue Cross of ID	Default	Percent of Total Billed Charges	868.64				142.63	868.64
CARDIOVERSION	92960	HCPCS	761	RC		both	895.5	761.18	Medicaid Idaho	Default	Fee Schedule	411.93				142.63	868.64
CARDIOVERSION	92960	HCPCS	761	RC		both	895.5	761.18	Medicare A ID JF	Default	Other	349.25		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	142.63	868.64
CARDIOVERSION	92960	HCPCS	761	RC		both	895.5	761.18	Medicare B ID JF	Default	Fee Schedule	142.63		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		142.63	868.64
CARDIOVERSION	92960	HCPCS	761	RC		both	895.5	761.18	Regence Group Administrators	Default	Fee Schedule	868.64				142.63	868.64
CARDIOVERSION	92960	HCPCS	761	RC		both	895.5	761.18	SelectHealth	Default	Percent of Total Billed Charges	850.72				142.63	868.64
UPR/LWR XTREMITY ARTERL BILAT 1 - 2 LEV	93922	HCPCS	921	RC		both	435.5	370.18	Blue Cross of ID	Default	Percent of Total Billed Charges	422.44				74.68	422.44
UPR/LWR XTREMITY ARTERL BILAT 1 - 2 LEV	93922	HCPCS	921	RC		both	435.5	370.18	Medicaid Idaho	Default	Fee Schedule	200.33				74.68	422.44
UPR/LWR XTREMITY ARTERL BILAT 1 - 2 LEV	93922	HCPCS	921	RC		both	435.5	370.18	Medicare A ID JF	Default	Other	169.85		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	74.68	422.44
UPR/LWR XTREMITY ARTERL BILAT 1 - 2 LEV	93922	HCPCS	921	RC		both	435.5	370.18	Medicare B ID JF	Default	Fee Schedule	74.68		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		74.68	422.44
UPR/LWR XTREMITY ARTERL BILAT 1 - 2 LEV	93922	HCPCS	921	RC		both	435.5	370.18	Regence Group Administrators	Default	Fee Schedule	422.44				74.68	422.44
UPR/LWR XTREMITY ARTERL BILAT 1 - 2 LEV	93922	HCPCS	921	RC		both	435.5	370.18	SelectHealth	Default	Percent of Total Billed Charges	413.72				74.68	422.44
2X3 CM CYGNUS MAX UMBILLICAL CORD	Q4199	HCPCS	636	RC		both	419.5	356.58	Blue Cross of ID	Default	Percent of Total Billed Charges	406.92				163.61	406.92
2X3 CM CYGNUS MAX UMBILLICAL CORD	Q4199	HCPCS	636	RC		both	419.5	356.58	Medicaid Idaho	Default	Fee Schedule	192.97				163.61	406.92
2X3 CM CYGNUS MAX UMBILLICAL CORD	Q4199	HCPCS	636	RC		both	419.5	356.58	Medicare A ID JF	Default	Other	163.61		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	163.61	406.92
2X3 CM CYGNUS MAX UMBILLICAL CORD	Q4199	HCPCS	636	RC		both	419.5	356.58	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		163.61	406.92
2X3 CM CYGNUS MAX UMBILLICAL CORD	Q4199	HCPCS	636	RC		both	419.5	356.58	Regence Group Administrators	Default	Fee Schedule	406.92				163.61	406.92
2X3 CM CYGNUS MAX UMBILLICAL CORD	Q4199	HCPCS	636	RC		both	419.5	356.58	SelectHealth	Default	Percent of Total Billed Charges	398.52				163.61	406.92
TB INJECTION	90471	HCPCS	761	RC		both	43	36.55	Blue Cross of ID	Default	Percent of Total Billed Charges	41.71				16.77	41.71
TB INJECTION	90471	HCPCS	761	RC		both	43	36.55	Medicaid Idaho	Default	Fee Schedule	19.29				16.77	41.71
TB INJECTION	90471	HCPCS	761	RC		both	43	36.55	Medicare A ID JF	Default	Other	16.77		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	16.77	41.71
TB INJECTION	90471	HCPCS	761	RC		both	43	36.55	Medicare B ID JF	Default	Fee Schedule	19.11		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		16.77	41.71
TB INJECTION	90471	HCPCS	761	RC		both	43	36.55	Regence Group Administrators	Default	Fee Schedule	41.71				16.77	41.71
TB INJECTION	90471	HCPCS	761	RC		both	43	36.55	SelectHealth	Default	Percent of Total Billed Charges	40.85				16.77	41.71
CHEMO ADMIN IVP	96411	HCPCS	761	RC		both	253	215.05	Blue Cross of ID	Default	Percent of Total Billed Charges	245.41				49.43	245.41
CHEMO ADMIN IVP	96411	HCPCS	761	RC		both	253	215.05	Medicaid Idaho	Default	Fee Schedule	116.38				49.43	245.41
CHEMO ADMIN IVP	96411	HCPCS	761	RC		both	253	215.05	Medicare A ID JF	Default	Other	98.67		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	49.43	245.41
CHEMO ADMIN IVP	96411	HCPCS	761	RC		both	253	215.05	Medicare B ID JF	Default	Fee Schedule	49.43		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		49.43	245.41
CHEMO ADMIN IVP	96411	HCPCS	761	RC		both	253	215.05	Regence Group Administrators	Default	Fee Schedule	245.41				49.43	245.41
CHEMO ADMIN IVP	96411	HCPCS	761	RC		both	253	215.05	SelectHealth	Default	Percent of Total Billed Charges	240.35				49.43	245.41
IRRIGATE PICC LINE	96523	HCPCS	761	RC		both	245	208.25	Blue Cross of ID	Default	Percent of Total Billed Charges	237.65				22.64	237.65
IRRIGATE PICC LINE	96523	HCPCS	761	RC		both	245	208.25	Medicaid Idaho	Default	Fee Schedule	112.7				22.64	237.65
IRRIGATE PICC LINE	96523	HCPCS	761	RC		both	245	208.25	Medicare A ID JF	Default	Other	95.55		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	22.64	237.65
IRRIGATE PICC LINE	96523	HCPCS	761	RC		both	245	208.25	Medicare B ID JF	Default	Fee Schedule	22.64		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		22.64	237.65
IRRIGATE PICC LINE	96523	HCPCS	761	RC		both	245	208.25	Regence Group Administrators	Default	Fee Schedule	237.65				22.64	237.65
IRRIGATE PICC LINE	96523	HCPCS	761	RC		both	245	208.25	SelectHealth	Default	Percent of Total Billed Charges	232.75				22.64	237.65
DEBRID OPEN WOUND 20 SQ CM OR LESS	97597	HCPCS	761	RC		both	222.5	189.13	Blue Cross of ID	Default	Percent of Total Billed Charges	215.82				86.78	215.82
DEBRID OPEN WOUND 20 SQ CM OR LESS	97597	HCPCS	761	RC		both	222.5	189.13	Medicaid Idaho	Default	Fee Schedule	102.35				86.78	215.82
DEBRID OPEN WOUND 20 SQ CM OR LESS	97597	HCPCS	761	RC		both	222.5	189.13	Medicare A ID JF	Default	Other	86.78		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	86.78	215.82
DEBRID OPEN WOUND 20 SQ CM OR LESS	97597	HCPCS	761	RC		both	222.5	189.13	Medicare B ID JF	Default	Fee Schedule	93.05		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		86.78	215.82
DEBRID OPEN WOUND 20 SQ CM OR LESS	97597	HCPCS	761	RC		both	222.5	189.13	Regence Group Administrators	Default	Fee Schedule	215.82				86.78	215.82
DEBRID OPEN WOUND 20 SQ CM OR LESS	97597	HCPCS	761	RC		both	222.5	189.13	SelectHealth	Default	Percent of Total Billed Charges	211.38				86.78	215.82
"DEBRIDEMENT, OPEN WOUND ADD 20 SQ CM"	97598	HCPCS	761	RC		both	248.5	211.23	Blue Cross of ID	Default	Percent of Total Billed Charges	241.04				41.44	241.04
"DEBRIDEMENT, OPEN WOUND ADD 20 SQ CM"	97598	HCPCS	761	RC		both	248.5	211.23	Medicaid Idaho	Default	Fee Schedule	114.31				41.44	241.04
"DEBRIDEMENT, OPEN WOUND ADD 20 SQ CM"	97598	HCPCS	761	RC		both	248.5	211.23	Medicare A ID JF	Default	Other	96.92		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	41.44	241.04
"DEBRIDEMENT, OPEN WOUND ADD 20 SQ CM"	97598	HCPCS	761	RC		both	248.5	211.23	Medicare B ID JF	Default	Fee Schedule	41.44		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		41.44	241.04
"DEBRIDEMENT, OPEN WOUND ADD 20 SQ CM"	97598	HCPCS	761	RC		both	248.5	211.23	Regence Group Administrators	Default	Fee Schedule	241.04				41.44	241.04
"DEBRIDEMENT, OPEN WOUND ADD 20 SQ CM"	97598	HCPCS	761	RC		both	248.5	211.23	SelectHealth	Default	Percent of Total Billed Charges	236.08				41.44	241.04
DEBRIDEMENT NON SELECT WET/DRY	97602	HCPCS	761	RC		both	191	162.35	Blue Cross of ID	Default	Percent of Total Billed Charges	185.27				74.49	185.27
DEBRIDEMENT NON SELECT WET/DRY	97602	HCPCS	761	RC		both	191	162.35	Medicaid Idaho	Default	Fee Schedule	87.86				74.49	185.27
DEBRIDEMENT NON SELECT WET/DRY	97602	HCPCS	761	RC		both	191	162.35	Medicare A ID JF	Default	Other	74.49		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	74.49	185.27
DEBRIDEMENT NON SELECT WET/DRY	97602	HCPCS	761	RC		both	191	162.35	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		74.49	185.27
DEBRIDEMENT NON SELECT WET/DRY	97602	HCPCS	761	RC		both	191	162.35	Regence Group Administrators	Default	Fee Schedule	185.27				74.49	185.27
DEBRIDEMENT NON SELECT WET/DRY	97602	HCPCS	761	RC		both	191	162.35	SelectHealth	Default	Percent of Total Billed Charges	181.45				74.49	185.27
NEGATIVE PRESSURE WOUND THERAPY 50 CM	97605	HCPCS	761	RC		both	191	162.35	Blue Cross of ID	Default	Percent of Total Billed Charges	185.27				40.53	185.27
NEGATIVE PRESSURE WOUND THERAPY 50 CM	97605	HCPCS	761	RC		both	191	162.35	Medicaid Idaho	Default	Fee Schedule	87.86				40.53	185.27
NEGATIVE PRESSURE WOUND THERAPY 50 CM	97605	HCPCS	761	RC		both	191	162.35	Medicare A ID JF	Default	Other	74.49		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	40.53	185.27
NEGATIVE PRESSURE WOUND THERAPY 50 CM	97605	HCPCS	761	RC		both	191	162.35	Medicare B ID JF	Default	Fee Schedule	40.53		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		40.53	185.27
NEGATIVE PRESSURE WOUND THERAPY 50 CM	97605	HCPCS	761	RC		both	191	162.35	Regence Group Administrators	Default	Fee Schedule	185.27				40.53	185.27
NEGATIVE PRESSURE WOUND THERAPY 50 CM	97605	HCPCS	761	RC		both	191	162.35	SelectHealth	Default	Percent of Total Billed Charges	181.45				40.53	185.27
NEGATIVE PRESSURE WOUND THERAPY < 50	97606	HCPCS	761	RC		both	275.5	234.18	Blue Cross of ID	Default	Percent of Total Billed Charges	267.24				47.93	267.24
NEGATIVE PRESSURE WOUND THERAPY < 50	97606	HCPCS	761	RC		both	275.5	234.18	Medicaid Idaho	Default	Fee Schedule	126.73				47.93	267.24
NEGATIVE PRESSURE WOUND THERAPY < 50	97606	HCPCS	761	RC		both	275.5	234.18	Medicare A ID JF	Default	Other	107.45		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	47.93	267.24
NEGATIVE PRESSURE WOUND THERAPY < 50	97606	HCPCS	761	RC		both	275.5	234.18	Medicare B ID JF	Default	Fee Schedule	47.93		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		47.93	267.24
NEGATIVE PRESSURE WOUND THERAPY < 50	97606	HCPCS	761	RC		both	275.5	234.18	Regence Group Administrators	Default	Fee Schedule	267.24				47.93	267.24
NEGATIVE PRESSURE WOUND THERAPY < 50	97606	HCPCS	761	RC		both	275.5	234.18	SelectHealth	Default	Percent of Total Billed Charges	261.72				47.93	267.24
NEGATIVE PRESSURE WOUND THERAPY	97607	HCPCS	761	RC		both	661.5	562.28	Blue Cross of ID	Default	Percent of Total Billed Charges	641.66				257.99	641.66
NEGATIVE PRESSURE WOUND THERAPY	97607	HCPCS	761	RC		both	661.5	562.28	Medicaid Idaho	Default	Fee Schedule	304.29				257.99	641.66
NEGATIVE PRESSURE WOUND THERAPY	97607	HCPCS	761	RC		both	661.5	562.28	Medicare A ID JF	Default	Other	257.99		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	257.99	641.66
NEGATIVE PRESSURE WOUND THERAPY	97607	HCPCS	761	RC		both	661.5	562.28	Medicare B ID JF	Default	Fee Schedule	316.21		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		257.99	641.66
NEGATIVE PRESSURE WOUND THERAPY	97607	HCPCS	761	RC		both	661.5	562.28	Regence Group Administrators	Default	Fee Schedule	641.66				257.99	641.66
NEGATIVE PRESSURE WOUND THERAPY	97607	HCPCS	761	RC		both	661.5	562.28	SelectHealth	Default	Percent of Total Billed Charges	628.42				257.99	641.66
NEG PRESSURE WOUND NON DURABLE	97608	HCPCS	761	RC		both	645	548.25	Blue Cross of ID	Default	Percent of Total Billed Charges	625.65				251.55	625.65
NEG PRESSURE WOUND NON DURABLE	97608	HCPCS	761	RC		both	645	548.25	Medicaid Idaho	Default	Fee Schedule	296.7				251.55	625.65
NEG PRESSURE WOUND NON DURABLE	97608	HCPCS	761	RC		both	645	548.25	Medicare A ID JF	Default	Other	251.55		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	251.55	625.65
NEG PRESSURE WOUND NON DURABLE	97608	HCPCS	761	RC		both	645	548.25	Medicare B ID JF	Default	Fee Schedule	326.8		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		251.55	625.65
NEG PRESSURE WOUND NON DURABLE	97608	HCPCS	761	RC		both	645	548.25	Regence Group Administrators	Default	Fee Schedule	625.65				251.55	625.65
NEG PRESSURE WOUND NON DURABLE	97608	HCPCS	761	RC		both	645	548.25	SelectHealth	Default	Percent of Total Billed Charges	612.75				251.55	625.65
CONSCIENCE SEDATION	99152	HCPCS	761	RC		both	730.5	620.93	Blue Cross of ID	Default	Percent of Total Billed Charges	708.58				45.96	708.58
CONSCIENCE SEDATION	99152	HCPCS	761	RC		both	730.5	620.93	Medicaid Idaho	Default	Fee Schedule	336.03				45.96	708.58
CONSCIENCE SEDATION	99152	HCPCS	761	RC		both	730.5	620.93	Medicare A ID JF	Default	Other	284.9		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	45.96	708.58
CONSCIENCE SEDATION	99152	HCPCS	761	RC		both	730.5	620.93	Medicare B ID JF	Default	Fee Schedule	45.96		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		45.96	708.58
CONSCIENCE SEDATION	99152	HCPCS	761	RC		both	730.5	620.93	Regence Group Administrators	Default	Fee Schedule	708.58				45.96	708.58
CONSCIENCE SEDATION	99152	HCPCS	761	RC		both	730.5	620.93	SelectHealth	Default	Percent of Total Billed Charges	693.98				45.96	708.58
PHLEBOTOMY THERAPEUTIC	99195	HCPCS	761	RC		both	235.5	200.18	Blue Cross of ID	Default	Percent of Total Billed Charges	228.44				85.85	228.44
PHLEBOTOMY THERAPEUTIC	99195	HCPCS	761	RC		both	235.5	200.18	Medicaid Idaho	Default	Fee Schedule	108.33				85.85	228.44
PHLEBOTOMY THERAPEUTIC	99195	HCPCS	761	RC		both	235.5	200.18	Medicare A ID JF	Default	Other	91.85		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	85.85	228.44
PHLEBOTOMY THERAPEUTIC	99195	HCPCS	761	RC		both	235.5	200.18	Medicare B ID JF	Default	Fee Schedule	85.85		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		85.85	228.44
PHLEBOTOMY THERAPEUTIC	99195	HCPCS	761	RC		both	235.5	200.18	Regence Group Administrators	Default	Fee Schedule	228.44				85.85	228.44
PHLEBOTOMY THERAPEUTIC	99195	HCPCS	761	RC		both	235.5	200.18	SelectHealth	Default	Percent of Total Billed Charges	223.72				85.85	228.44
002CLINIC E&M LEVEL1	99211	HCPCS	761	RC		both	170	144.5	Blue Cross of ID	Default	Percent of Total Billed Charges	164.9				21.56	164.9
002CLINIC E&M LEVEL1	99211	HCPCS	761	RC		both	170	144.5	Medicaid Idaho	Default	Fee Schedule	78.2				21.56	164.9
002CLINIC E&M LEVEL1	99211	HCPCS	761	RC		both	170	144.5	Medicare A ID JF	Default	Other	66.3		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	21.56	164.9
002CLINIC E&M LEVEL1	99211	HCPCS	761	RC		both	170	144.5	Medicare B ID JF	Default	Fee Schedule	21.56		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		21.56	164.9
002CLINIC E&M LEVEL1	99211	HCPCS	761	RC		both	170	144.5	Regence Group Administrators	Default	Fee Schedule	164.9				21.56	164.9
002CLINIC E&M LEVEL1	99211	HCPCS	761	RC		both	170	144.5	SelectHealth	Default	Percent of Total Billed Charges	161.5				21.56	164.9
CLINIC E&M LEVEL2	99212	HCPCS	761	RC		outpatient	232.5	197.63	Blue Cross of ID	Default	Percent of Total Billed Charges	225.52				52.63	225.52
CLINIC E&M LEVEL2	99212	HCPCS	761	RC		outpatient	232.5	197.63	Medicaid Idaho	Default	Fee Schedule	106.95				52.63	225.52
CLINIC E&M LEVEL2	99212	HCPCS	761	RC		outpatient	232.5	197.63	Medicare A ID JF	Default	Other	90.68		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	52.63	225.52
CLINIC E&M LEVEL2	99212	HCPCS	761	RC		outpatient	232.5	197.63	Medicare B ID JF	Default	Fee Schedule	52.63		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		52.63	225.52
CLINIC E&M LEVEL2	99212	HCPCS	761	RC		outpatient	232.5	197.63	Regence Group Administrators	Default	Fee Schedule	225.52				52.63	225.52
CLINIC E&M LEVEL2	99212	HCPCS	761	RC		outpatient	232.5	197.63	SelectHealth	Default	Percent of Total Billed Charges	220.88				52.63	225.52
CLINIC E&M LEVEL3	99213	HCPCS	761	RC		outpatient	294	249.9	Blue Cross of ID	Default	Percent of Total Billed Charges	285.18				85.01	285.18
CLINIC E&M LEVEL3	99213	HCPCS	761	RC		outpatient	294	249.9	Medicaid Idaho	Default	Fee Schedule	135.24				85.01	285.18
CLINIC E&M LEVEL3	99213	HCPCS	761	RC		outpatient	294	249.9	Medicare A ID JF	Default	Other	114.66		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	85.01	285.18
CLINIC E&M LEVEL3	99213	HCPCS	761	RC		outpatient	294	249.9	Medicare B ID JF	Default	Fee Schedule	85.01		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		85.01	285.18
CLINIC E&M LEVEL3	99213	HCPCS	761	RC		outpatient	294	249.9	Regence Group Administrators	Default	Fee Schedule	285.18				85.01	285.18
CLINIC E&M LEVEL3	99213	HCPCS	761	RC		outpatient	294	249.9	SelectHealth	Default	Percent of Total Billed Charges	279.3				85.01	285.18
CHEMO EXTEND IV INFUS W/ PUMP	G0498	HCPCS	280	RC		both	393	334.05	Blue Cross of ID	Default	Percent of Total Billed Charges	381.21				153.27	381.21
CHEMO EXTEND IV INFUS W/ PUMP	G0498	HCPCS	280	RC		both	393	334.05	Medicaid Idaho	Default	Fee Schedule	180.78				153.27	381.21
CHEMO EXTEND IV INFUS W/ PUMP	G0498	HCPCS	280	RC		both	393	334.05	Medicare A ID JF	Default	Other	153.27		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	153.27	381.21
CHEMO EXTEND IV INFUS W/ PUMP	G0498	HCPCS	280	RC		both	393	334.05	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		153.27	381.21
CHEMO EXTEND IV INFUS W/ PUMP	G0498	HCPCS	280	RC		both	393	334.05	Regence Group Administrators	Default	Fee Schedule	381.21				153.27	381.21
CHEMO EXTEND IV INFUS W/ PUMP	G0498	HCPCS	280	RC		both	393	334.05	SelectHealth	Default	Percent of Total Billed Charges	373.35				153.27	381.21
"FINE NEEDLE ASPIRATION, BIOPSY 1ST LESIO"	10021	HCPCS	450	RC		outpatient	307	260.95	Blue Cross of ID	Default	Percent of Total Billed Charges	297.79				92.96	297.79
"FINE NEEDLE ASPIRATION, BIOPSY 1ST LESIO"	10021	HCPCS	450	RC		outpatient	307	260.95	Medicaid Idaho	Default	Fee Schedule	141.22				92.96	297.79
"FINE NEEDLE ASPIRATION, BIOPSY 1ST LESIO"	10021	HCPCS	450	RC		outpatient	307	260.95	Medicare A ID JF	Default	Other	119.73		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	92.96	297.79
"FINE NEEDLE ASPIRATION, BIOPSY 1ST LESIO"	10021	HCPCS	450	RC		outpatient	307	260.95	Medicare B ID JF	Default	Fee Schedule	92.96		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		92.96	297.79
"FINE NEEDLE ASPIRATION, BIOPSY 1ST LESIO"	10021	HCPCS	450	RC		outpatient	307	260.95	Regence Group Administrators	Default	Fee Schedule	297.79				92.96	297.79
"FINE NEEDLE ASPIRATION, BIOPSY 1ST LESIO"	10021	HCPCS	450	RC		outpatient	307	260.95	SelectHealth	Default	Percent of Total Billed Charges	291.65				92.96	297.79
INCISION AND DRAINAGE OF ABCESS	10060	HCPCS	450	RC		outpatient	405	344.25	Blue Cross of ID	Default	Percent of Total Billed Charges	392.85				117.56	392.85
INCISION AND DRAINAGE OF ABCESS	10060	HCPCS	450	RC		outpatient	405	344.25	Medicaid Idaho	Default	Fee Schedule	186.3				117.56	392.85
INCISION AND DRAINAGE OF ABCESS	10060	HCPCS	450	RC		outpatient	405	344.25	Medicare A ID JF	Default	Other	157.95		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	117.56	392.85
INCISION AND DRAINAGE OF ABCESS	10060	HCPCS	450	RC		outpatient	405	344.25	Medicare B ID JF	Default	Fee Schedule	117.56		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		117.56	392.85
INCISION AND DRAINAGE OF ABCESS	10060	HCPCS	450	RC		outpatient	405	344.25	Regence Group Administrators	Default	Fee Schedule	392.85				117.56	392.85
INCISION AND DRAINAGE OF ABCESS	10060	HCPCS	450	RC		outpatient	405	344.25	SelectHealth	Default	Percent of Total Billed Charges	384.75				117.56	392.85
INCISION/DRAIANGE COMPLICATED OR MULTIPL	10061	HCPCS	450	RC		outpatient	524.5	445.83	Blue Cross of ID	Default	Percent of Total Billed Charges	508.76				198.3	508.76
INCISION/DRAIANGE COMPLICATED OR MULTIPL	10061	HCPCS	450	RC		outpatient	524.5	445.83	Medicaid Idaho	Default	Fee Schedule	241.27				198.3	508.76
INCISION/DRAIANGE COMPLICATED OR MULTIPL	10061	HCPCS	450	RC		outpatient	524.5	445.83	Medicare A ID JF	Default	Other	204.56		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	198.3	508.76
INCISION/DRAIANGE COMPLICATED OR MULTIPL	10061	HCPCS	450	RC		outpatient	524.5	445.83	Medicare B ID JF	Default	Fee Schedule	198.3		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		198.3	508.76
INCISION/DRAIANGE COMPLICATED OR MULTIPL	10061	HCPCS	450	RC		outpatient	524.5	445.83	Regence Group Administrators	Default	Fee Schedule	508.76				198.3	508.76
INCISION/DRAIANGE COMPLICATED OR MULTIPL	10061	HCPCS	450	RC		outpatient	524.5	445.83	SelectHealth	Default	Percent of Total Billed Charges	498.28				198.3	508.76
EXCISION PILONIDAL CYST SIMPLE	11770	HCPCS	450	RC		outpatient	2635	2239.75	Blue Cross of ID	Default	Percent of Total Billed Charges	2555.95				321.72	2555.95
EXCISION PILONIDAL CYST SIMPLE	11770	HCPCS	450	RC		outpatient	2635	2239.75	Medicaid Idaho	Default	Fee Schedule	1212.1				321.72	2555.95
EXCISION PILONIDAL CYST SIMPLE	11770	HCPCS	450	RC		outpatient	2635	2239.75	Medicare A ID JF	Default	Other	1027.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	321.72	2555.95
EXCISION PILONIDAL CYST SIMPLE	11770	HCPCS	450	RC		outpatient	2635	2239.75	Medicare B ID JF	Default	Fee Schedule	321.72		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		321.72	2555.95
EXCISION PILONIDAL CYST SIMPLE	11770	HCPCS	450	RC		outpatient	2635	2239.75	Regence Group Administrators	Default	Fee Schedule	2555.95				321.72	2555.95
EXCISION PILONIDAL CYST SIMPLE	11770	HCPCS	450	RC		outpatient	2635	2239.75	SelectHealth	Default	Percent of Total Billed Charges	2503.25				321.72	2555.95
FB REMOVAL SUBCU TISSUE SIMPLE	10120	HCPCS	450	RC		outpatient	370.5	314.93	Blue Cross of ID	Default	Percent of Total Billed Charges	359.38				140.24	359.38
FB REMOVAL SUBCU TISSUE SIMPLE	10120	HCPCS	450	RC		outpatient	370.5	314.93	Medicaid Idaho	Default	Fee Schedule	170.43				140.24	359.38
FB REMOVAL SUBCU TISSUE SIMPLE	10120	HCPCS	450	RC		outpatient	370.5	314.93	Medicare A ID JF	Default	Other	144.5		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	140.24	359.38
FB REMOVAL SUBCU TISSUE SIMPLE	10120	HCPCS	450	RC		outpatient	370.5	314.93	Medicare B ID JF	Default	Fee Schedule	140.24		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		140.24	359.38
FB REMOVAL SUBCU TISSUE SIMPLE	10120	HCPCS	450	RC		outpatient	370.5	314.93	Regence Group Administrators	Default	Fee Schedule	359.38				140.24	359.38
FB REMOVAL SUBCU TISSUE SIMPLE	10120	HCPCS	450	RC		outpatient	370.5	314.93	SelectHealth	Default	Percent of Total Billed Charges	351.98				140.24	359.38
I/D OF HEMATOMA/SEROMA	10140	HCPCS	450	RC		outpatient	1480	1258	Blue Cross of ID	Default	Percent of Total Billed Charges	1435.6				156.47	1435.6
I/D OF HEMATOMA/SEROMA	10140	HCPCS	450	RC		outpatient	1480	1258	Medicaid Idaho	Default	Fee Schedule	680.8				156.47	1435.6
I/D OF HEMATOMA/SEROMA	10140	HCPCS	450	RC		outpatient	1480	1258	Medicare A ID JF	Default	Other	577.2		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	156.47	1435.6
I/D OF HEMATOMA/SEROMA	10140	HCPCS	450	RC		outpatient	1480	1258	Medicare B ID JF	Default	Fee Schedule	156.47		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		156.47	1435.6
I/D OF HEMATOMA/SEROMA	10140	HCPCS	450	RC		outpatient	1480	1258	Regence Group Administrators	Default	Fee Schedule	1435.6				156.47	1435.6
I/D OF HEMATOMA/SEROMA	10140	HCPCS	450	RC		outpatient	1480	1258	SelectHealth	Default	Percent of Total Billed Charges	1406				156.47	1435.6
"PUNCT ASPIR OF ABSCESS, HEMA, BULLA, CYS"	10160	HCPCS	450	RC		outpatient	373	317.05	Blue Cross of ID	Default	Percent of Total Billed Charges	361.81				119.63	361.81
"PUNCT ASPIR OF ABSCESS, HEMA, BULLA, CYS"	10160	HCPCS	450	RC		outpatient	373	317.05	Medicaid Idaho	Default	Fee Schedule	171.58				119.63	361.81
"PUNCT ASPIR OF ABSCESS, HEMA, BULLA, CYS"	10160	HCPCS	450	RC		outpatient	373	317.05	Medicare A ID JF	Default	Other	145.47		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	119.63	361.81
"PUNCT ASPIR OF ABSCESS, HEMA, BULLA, CYS"	10160	HCPCS	450	RC		outpatient	373	317.05	Medicare B ID JF	Default	Fee Schedule	119.63		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		119.63	361.81
"PUNCT ASPIR OF ABSCESS, HEMA, BULLA, CYS"	10160	HCPCS	450	RC		outpatient	373	317.05	Regence Group Administrators	Default	Fee Schedule	361.81				119.63	361.81
"PUNCT ASPIR OF ABSCESS, HEMA, BULLA, CYS"	10160	HCPCS	450	RC		outpatient	373	317.05	SelectHealth	Default	Percent of Total Billed Charges	354.35				119.63	361.81
I/D COMPLEX POST OP INF	10180	HCPCS	450	RC		outpatient	2470.5	2099.93	Blue Cross of ID	Default	Percent of Total Billed Charges	2396.38				238.84	2396.38
I/D COMPLEX POST OP INF	10180	HCPCS	450	RC		outpatient	2470.5	2099.93	Medicaid Idaho	Default	Fee Schedule	1136.43				238.84	2396.38
I/D COMPLEX POST OP INF	10180	HCPCS	450	RC		outpatient	2470.5	2099.93	Medicare A ID JF	Default	Other	963.5		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	238.84	2396.38
I/D COMPLEX POST OP INF	10180	HCPCS	450	RC		outpatient	2470.5	2099.93	Medicare B ID JF	Default	Fee Schedule	238.84		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		238.84	2396.38
I/D COMPLEX POST OP INF	10180	HCPCS	450	RC		outpatient	2470.5	2099.93	Regence Group Administrators	Default	Fee Schedule	2396.38				238.84	2396.38
I/D COMPLEX POST OP INF	10180	HCPCS	450	RC		outpatient	2470.5	2099.93	SelectHealth	Default	Percent of Total Billed Charges	2346.98				238.84	2396.38
HYDRATION IV INFUSION INIT 31 MIN-1 HOUR	96360	HCPCS	260	RC		both	361.5	307.28	Blue Cross of ID	Default	Percent of Total Billed Charges	350.66				29.69	350.66
HYDRATION IV INFUSION INIT 31 MIN-1 HOUR	96360	HCPCS	260	RC		both	361.5	307.28	Medicaid Idaho	Default	Fee Schedule	166.29				29.69	350.66
HYDRATION IV INFUSION INIT 31 MIN-1 HOUR	96360	HCPCS	260	RC		both	361.5	307.28	Medicare A ID JF	Default	Other	140.99		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	29.69	350.66
HYDRATION IV INFUSION INIT 31 MIN-1 HOUR	96360	HCPCS	260	RC		both	361.5	307.28	Medicare B ID JF	Default	Fee Schedule	29.69		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		29.69	350.66
HYDRATION IV INFUSION INIT 31 MIN-1 HOUR	96360	HCPCS	260	RC		both	361.5	307.28	Regence Group Administrators	Default	Fee Schedule	350.66				29.69	350.66
HYDRATION IV INFUSION INIT 31 MIN-1 HOUR	96360	HCPCS	260	RC		both	361.5	307.28	SelectHealth	Default	Percent of Total Billed Charges	343.42				29.69	350.66
HYDRATION IV INFUSION INIT 31 MIN-1 HOUR	96360	HCPCS	260	RC	59	both	361.5	307.28	Blue Cross of ID	Default	Percent of Total Billed Charges	350.66				29.69	350.66
HYDRATION IV INFUSION INIT 31 MIN-1 HOUR	96360	HCPCS	260	RC	59	both	361.5	307.28	Medicaid Idaho	Default	Fee Schedule	166.29				29.69	350.66
HYDRATION IV INFUSION INIT 31 MIN-1 HOUR	96360	HCPCS	260	RC	59	both	361.5	307.28	Medicare A ID JF	Default	Other	140.99		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	29.69	350.66
HYDRATION IV INFUSION INIT 31 MIN-1 HOUR	96360	HCPCS	260	RC	59	both	361.5	307.28	Medicare B ID JF	Default	Fee Schedule	29.69		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		29.69	350.66
HYDRATION IV INFUSION INIT 31 MIN-1 HOUR	96360	HCPCS	260	RC	59	both	361.5	307.28	Regence Group Administrators	Default	Fee Schedule	350.66				29.69	350.66
HYDRATION IV INFUSION INIT 31 MIN-1 HOUR	96360	HCPCS	260	RC	59	both	361.5	307.28	SelectHealth	Default	Percent of Total Billed Charges	343.42				29.69	350.66
HYDRATE IV INFUSION ADD-ON	96361	HCPCS	260	RC		both	132	112.2	Blue Cross of ID	Default	Percent of Total Billed Charges	128.04				11.31	128.04
HYDRATE IV INFUSION ADD-ON	96361	HCPCS	260	RC		both	132	112.2	Medicaid Idaho	Default	Fee Schedule	60.72				11.31	128.04
HYDRATE IV INFUSION ADD-ON	96361	HCPCS	260	RC		both	132	112.2	Medicare A ID JF	Default	Other	51.48		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	11.31	128.04
HYDRATE IV INFUSION ADD-ON	96361	HCPCS	260	RC		both	132	112.2	Medicare B ID JF	Default	Fee Schedule	11.31		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		11.31	128.04
HYDRATE IV INFUSION ADD-ON	96361	HCPCS	260	RC		both	132	112.2	Regence Group Administrators	Default	Fee Schedule	128.04				11.31	128.04
HYDRATE IV INFUSION ADD-ON	96361	HCPCS	260	RC		both	132	112.2	SelectHealth	Default	Percent of Total Billed Charges	125.4				11.31	128.04
HYDRATE IV INFUSION ADD-ON	96361	HCPCS	260	RC	59	both	132	112.2	Blue Cross of ID	Default	Percent of Total Billed Charges	128.04				11.31	128.04
HYDRATE IV INFUSION ADD-ON	96361	HCPCS	260	RC	59	both	132	112.2	Medicaid Idaho	Default	Fee Schedule	60.72				11.31	128.04
HYDRATE IV INFUSION ADD-ON	96361	HCPCS	260	RC	59	both	132	112.2	Medicare A ID JF	Default	Other	51.48		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	11.31	128.04
HYDRATE IV INFUSION ADD-ON	96361	HCPCS	260	RC	59	both	132	112.2	Medicare B ID JF	Default	Fee Schedule	11.31		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		11.31	128.04
HYDRATE IV INFUSION ADD-ON	96361	HCPCS	260	RC	59	both	132	112.2	Regence Group Administrators	Default	Fee Schedule	128.04				11.31	128.04
HYDRATE IV INFUSION ADD-ON	96361	HCPCS	260	RC	59	both	132	112.2	SelectHealth	Default	Percent of Total Billed Charges	125.4				11.31	128.04
THER/PROPH/DIAG IV INF INIT	96365	HCPCS	260	RC		both	429.5	365.08	Blue Cross of ID	Default	Percent of Total Billed Charges	416.62				56.87	416.62
THER/PROPH/DIAG IV INF INIT	96365	HCPCS	260	RC		both	429.5	365.08	Medicaid Idaho	Default	Fee Schedule	197.57				56.87	416.62
THER/PROPH/DIAG IV INF INIT	96365	HCPCS	260	RC		both	429.5	365.08	Medicare A ID JF	Default	Other	167.51		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	56.87	416.62
THER/PROPH/DIAG IV INF INIT	96365	HCPCS	260	RC		both	429.5	365.08	Medicare B ID JF	Default	Fee Schedule	56.87		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		56.87	416.62
THER/PROPH/DIAG IV INF INIT	96365	HCPCS	260	RC		both	429.5	365.08	Regence Group Administrators	Default	Fee Schedule	416.62				56.87	416.62
THER/PROPH/DIAG IV INF INIT	96365	HCPCS	260	RC		both	429.5	365.08	SelectHealth	Default	Percent of Total Billed Charges	408.02				56.87	416.62
THER/PROPH/DIAG IV INF INIT	96365	HCPCS	260	RC	59	both	429.5	365.08	Blue Cross of ID	Default	Percent of Total Billed Charges	416.62				56.87	416.62
THER/PROPH/DIAG IV INF INIT	96365	HCPCS	260	RC	59	both	429.5	365.08	Medicaid Idaho	Default	Fee Schedule	197.57				56.87	416.62
THER/PROPH/DIAG IV INF INIT	96365	HCPCS	260	RC	59	both	429.5	365.08	Medicare A ID JF	Default	Other	167.51		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	56.87	416.62
THER/PROPH/DIAG IV INF INIT	96365	HCPCS	260	RC	59	both	429.5	365.08	Medicare B ID JF	Default	Fee Schedule	56.87		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		56.87	416.62
THER/PROPH/DIAG IV INF INIT	96365	HCPCS	260	RC	59	both	429.5	365.08	Regence Group Administrators	Default	Fee Schedule	416.62				56.87	416.62
THER/PROPH/DIAG IV INF INIT	96365	HCPCS	260	RC	59	both	429.5	365.08	SelectHealth	Default	Percent of Total Billed Charges	408.02				56.87	416.62
THER/PROPH/DIAG IV INF ADD-ON	96366	HCPCS	260	RC		both	140.5	119.43	Blue Cross of ID	Default	Percent of Total Billed Charges	136.28				18.84	136.28
THER/PROPH/DIAG IV INF ADD-ON	96366	HCPCS	260	RC		both	140.5	119.43	Medicaid Idaho	Default	Fee Schedule	64.63				18.84	136.28
THER/PROPH/DIAG IV INF ADD-ON	96366	HCPCS	260	RC		both	140.5	119.43	Medicare A ID JF	Default	Other	54.8		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	18.84	136.28
THER/PROPH/DIAG IV INF ADD-ON	96366	HCPCS	260	RC		both	140.5	119.43	Medicare B ID JF	Default	Fee Schedule	18.84		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		18.84	136.28
THER/PROPH/DIAG IV INF ADD-ON	96366	HCPCS	260	RC		both	140.5	119.43	Regence Group Administrators	Default	Fee Schedule	136.28				18.84	136.28
THER/PROPH/DIAG IV INF ADD-ON	96366	HCPCS	260	RC		both	140.5	119.43	SelectHealth	Default	Percent of Total Billed Charges	133.48				18.84	136.28
THER/PROPH/DIAG IV INF ADD-ON	96366	HCPCS	260	RC	59	both	140.5	119.43	Blue Cross of ID	Default	Percent of Total Billed Charges	136.28				18.84	136.28
THER/PROPH/DIAG IV INF ADD-ON	96366	HCPCS	260	RC	59	both	140.5	119.43	Medicaid Idaho	Default	Fee Schedule	64.63				18.84	136.28
THER/PROPH/DIAG IV INF ADD-ON	96366	HCPCS	260	RC	59	both	140.5	119.43	Medicare A ID JF	Default	Other	54.8		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	18.84	136.28
THER/PROPH/DIAG IV INF ADD-ON	96366	HCPCS	260	RC	59	both	140.5	119.43	Medicare B ID JF	Default	Fee Schedule	18.84		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		18.84	136.28
THER/PROPH/DIAG IV INF ADD-ON	96366	HCPCS	260	RC	59	both	140.5	119.43	Regence Group Administrators	Default	Fee Schedule	136.28				18.84	136.28
THER/PROPH/DIAG IV INF ADD-ON	96366	HCPCS	260	RC	59	both	140.5	119.43	SelectHealth	Default	Percent of Total Billed Charges	133.48				18.84	136.28
TX /PROPH /DG /ADDL SEQ IN INF	96367	HCPCS	260	RC		both	169.5	144.08	Blue Cross of ID	Default	Percent of Total Billed Charges	164.42				26.12	164.42
TX /PROPH /DG /ADDL SEQ IN INF	96367	HCPCS	260	RC		both	169.5	144.08	Medicaid Idaho	Default	Fee Schedule	77.97				26.12	164.42
TX /PROPH /DG /ADDL SEQ IN INF	96367	HCPCS	260	RC		both	169.5	144.08	Medicare A ID JF	Default	Other	66.11		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	26.12	164.42
TX /PROPH /DG /ADDL SEQ IN INF	96367	HCPCS	260	RC		both	169.5	144.08	Medicare B ID JF	Default	Fee Schedule	26.12		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		26.12	164.42
TX /PROPH /DG /ADDL SEQ IN INF	96367	HCPCS	260	RC		both	169.5	144.08	Regence Group Administrators	Default	Fee Schedule	164.42				26.12	164.42
TX /PROPH /DG /ADDL SEQ IN INF	96367	HCPCS	260	RC		both	169.5	144.08	SelectHealth	Default	Percent of Total Billed Charges	161.02				26.12	164.42
TX /PROPH /DG /ADDL SEQ IN INF	96367	HCPCS	260	RC	59	both	169.5	144.08	Blue Cross of ID	Default	Percent of Total Billed Charges	164.42				26.12	164.42
TX /PROPH /DG /ADDL SEQ IN INF	96367	HCPCS	260	RC	59	both	169.5	144.08	Medicaid Idaho	Default	Fee Schedule	77.97				26.12	164.42
TX /PROPH /DG /ADDL SEQ IN INF	96367	HCPCS	260	RC	59	both	169.5	144.08	Medicare A ID JF	Default	Other	66.11		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	26.12	164.42
TX /PROPH /DG /ADDL SEQ IN INF	96367	HCPCS	260	RC	59	both	169.5	144.08	Medicare B ID JF	Default	Fee Schedule	26.12		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		26.12	164.42
TX /PROPH /DG /ADDL SEQ IN INF	96367	HCPCS	260	RC	59	both	169.5	144.08	Regence Group Administrators	Default	Fee Schedule	164.42				26.12	164.42
TX /PROPH /DG /ADDL SEQ IN INF	96367	HCPCS	260	RC	59	both	169.5	144.08	SelectHealth	Default	Percent of Total Billed Charges	161.02				26.12	164.42
THER / DIAG CONCURRENT INF	96368	HCPCS	260	RC		both	138.5	117.73	Blue Cross of ID	Default	Percent of Total Billed Charges	134.34				18.2	134.34
THER / DIAG CONCURRENT INF	96368	HCPCS	260	RC		both	138.5	117.73	Medicaid Idaho	Default	Fee Schedule	63.71				18.2	134.34
THER / DIAG CONCURRENT INF	96368	HCPCS	260	RC		both	138.5	117.73	Medicare A ID JF	Default	Other	54.02		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	18.2	134.34
THER / DIAG CONCURRENT INF	96368	HCPCS	260	RC		both	138.5	117.73	Medicare B ID JF	Default	Fee Schedule	18.2		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		18.2	134.34
THER / DIAG CONCURRENT INF	96368	HCPCS	260	RC		both	138.5	117.73	Regence Group Administrators	Default	Fee Schedule	134.34				18.2	134.34
THER / DIAG CONCURRENT INF	96368	HCPCS	260	RC		both	138.5	117.73	SelectHealth	Default	Percent of Total Billed Charges	131.58				18.2	134.34
THER / DIAG CONCURRENT INF	96368	HCPCS	260	RC	59	both	138.5	117.73	Blue Cross of ID	Default	Percent of Total Billed Charges	134.34				18.2	134.34
THER / DIAG CONCURRENT INF	96368	HCPCS	260	RC	59	both	138.5	117.73	Medicaid Idaho	Default	Fee Schedule	63.71				18.2	134.34
THER / DIAG CONCURRENT INF	96368	HCPCS	260	RC	59	both	138.5	117.73	Medicare A ID JF	Default	Other	54.02		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	18.2	134.34
THER / DIAG CONCURRENT INF	96368	HCPCS	260	RC	59	both	138.5	117.73	Medicare B ID JF	Default	Fee Schedule	18.2		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		18.2	134.34
THER / DIAG CONCURRENT INF	96368	HCPCS	260	RC	59	both	138.5	117.73	Regence Group Administrators	Default	Fee Schedule	134.34				18.2	134.34
THER / DIAG CONCURRENT INF	96368	HCPCS	260	RC	59	both	138.5	117.73	SelectHealth	Default	Percent of Total Billed Charges	131.58				18.2	134.34
SC THER INFUSION UP TO 1 HR	96369	HCPCS	260	RC		both	340.5	289.43	Blue Cross of ID	Default	Percent of Total Billed Charges	330.28				128.35	330.28
SC THER INFUSION UP TO 1 HR	96369	HCPCS	260	RC		both	340.5	289.43	Medicaid Idaho	Default	Fee Schedule	156.63				128.35	330.28
SC THER INFUSION UP TO 1 HR	96369	HCPCS	260	RC		both	340.5	289.43	Medicare A ID JF	Default	Other	132.8		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	128.35	330.28
SC THER INFUSION UP TO 1 HR	96369	HCPCS	260	RC		both	340.5	289.43	Medicare B ID JF	Default	Fee Schedule	128.35		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		128.35	330.28
SC THER INFUSION UP TO 1 HR	96369	HCPCS	260	RC		both	340.5	289.43	Regence Group Administrators	Default	Fee Schedule	330.28				128.35	330.28
SC THER INFUSION UP TO 1 HR	96369	HCPCS	260	RC		both	340.5	289.43	SelectHealth	Default	Percent of Total Billed Charges	323.48				128.35	330.28
SC THER INFUSION UP TO 1 HR	96369	HCPCS	260	RC	59	both	340.5	289.43	Blue Cross of ID	Default	Percent of Total Billed Charges	330.28				128.35	330.28
SC THER INFUSION UP TO 1 HR	96369	HCPCS	260	RC	59	both	340.5	289.43	Medicaid Idaho	Default	Fee Schedule	156.63				128.35	330.28
SC THER INFUSION UP TO 1 HR	96369	HCPCS	260	RC	59	both	340.5	289.43	Medicare A ID JF	Default	Other	132.8		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	128.35	330.28
SC THER INFUSION UP TO 1 HR	96369	HCPCS	260	RC	59	both	340.5	289.43	Medicare B ID JF	Default	Fee Schedule	128.35		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		128.35	330.28
SC THER INFUSION UP TO 1 HR	96369	HCPCS	260	RC	59	both	340.5	289.43	Regence Group Administrators	Default	Fee Schedule	330.28				128.35	330.28
SC THER INFUSION UP TO 1 HR	96369	HCPCS	260	RC	59	both	340.5	289.43	SelectHealth	Default	Percent of Total Billed Charges	323.48				128.35	330.28
SC THER INFUSION ADDL HR	96370	HCPCS	260	RC		both	134	113.9	Blue Cross of ID	Default	Percent of Total Billed Charges	129.98				14.91	129.98
SC THER INFUSION ADDL HR	96370	HCPCS	260	RC		both	134	113.9	Medicaid Idaho	Default	Fee Schedule	61.64				14.91	129.98
SC THER INFUSION ADDL HR	96370	HCPCS	260	RC		both	134	113.9	Medicare A ID JF	Default	Other	52.26		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	14.91	129.98
SC THER INFUSION ADDL HR	96370	HCPCS	260	RC		both	134	113.9	Medicare B ID JF	Default	Fee Schedule	14.91		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		14.91	129.98
SC THER INFUSION ADDL HR	96370	HCPCS	260	RC		both	134	113.9	Regence Group Administrators	Default	Fee Schedule	129.98				14.91	129.98
SC THER INFUSION ADDL HR	96370	HCPCS	260	RC		both	134	113.9	SelectHealth	Default	Percent of Total Billed Charges	127.3				14.91	129.98
SC THER INFUSION ADDL HR	96370	HCPCS	260	RC	59	both	134	113.9	Blue Cross of ID	Default	Percent of Total Billed Charges	129.98				14.91	129.98
SC THER INFUSION ADDL HR	96370	HCPCS	260	RC	59	both	134	113.9	Medicaid Idaho	Default	Fee Schedule	61.64				14.91	129.98
SC THER INFUSION ADDL HR	96370	HCPCS	260	RC	59	both	134	113.9	Medicare A ID JF	Default	Other	52.26		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	14.91	129.98
SC THER INFUSION ADDL HR	96370	HCPCS	260	RC	59	both	134	113.9	Medicare B ID JF	Default	Fee Schedule	14.91		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		14.91	129.98
SC THER INFUSION ADDL HR	96370	HCPCS	260	RC	59	both	134	113.9	Regence Group Administrators	Default	Fee Schedule	129.98				14.91	129.98
SC THER INFUSION ADDL HR	96370	HCPCS	260	RC	59	both	134	113.9	SelectHealth	Default	Percent of Total Billed Charges	127.3				14.91	129.98
THER/PROPH/DIAG INJ SC / IM	96372	HCPCS	260	RC		both	125	106.25	Blue Cross of ID	Default	Percent of Total Billed Charges	121.25				13.37	121.25
THER/PROPH/DIAG INJ SC / IM	96372	HCPCS	260	RC		both	125	106.25	Medicaid Idaho	Default	Fee Schedule	57.5				13.37	121.25
THER/PROPH/DIAG INJ SC / IM	96372	HCPCS	260	RC		both	125	106.25	Medicare A ID JF	Default	Other	48.75		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	13.37	121.25
THER/PROPH/DIAG INJ SC / IM	96372	HCPCS	260	RC		both	125	106.25	Medicare B ID JF	Default	Fee Schedule	13.37		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		13.37	121.25
THER/PROPH/DIAG INJ SC / IM	96372	HCPCS	260	RC		both	125	106.25	Regence Group Administrators	Default	Fee Schedule	121.25				13.37	121.25
THER/PROPH/DIAG INJ SC / IM	96372	HCPCS	260	RC		both	125	106.25	SelectHealth	Default	Percent of Total Billed Charges	118.75				13.37	121.25
THER/PROPH/DIAG INJ SC / IM	96372	HCPCS	260	RC	59	both	125	106.25	Blue Cross of ID	Default	Percent of Total Billed Charges	121.25				13.37	121.25
THER/PROPH/DIAG INJ SC / IM	96372	HCPCS	260	RC	59	both	125	106.25	Medicaid Idaho	Default	Fee Schedule	57.5				13.37	121.25
THER/PROPH/DIAG INJ SC / IM	96372	HCPCS	260	RC	59	both	125	106.25	Medicare A ID JF	Default	Other	48.75		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	13.37	121.25
THER/PROPH/DIAG INJ SC / IM	96372	HCPCS	260	RC	59	both	125	106.25	Medicare B ID JF	Default	Fee Schedule	13.37		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		13.37	121.25
THER/PROPH/DIAG INJ SC / IM	96372	HCPCS	260	RC	59	both	125	106.25	Regence Group Administrators	Default	Fee Schedule	121.25				13.37	121.25
THER/PROPH/DIAG INJ SC / IM	96372	HCPCS	260	RC	59	both	125	106.25	SelectHealth	Default	Percent of Total Billed Charges	118.75				13.37	121.25
THER / PROPH / DIAG INJ IN PUSH	96374	HCPCS	260	RC		both	209.5	178.08	Blue Cross of ID	Default	Percent of Total Billed Charges	203.22				33.5	203.22
THER / PROPH / DIAG INJ IN PUSH	96374	HCPCS	260	RC		both	209.5	178.08	Medicaid Idaho	Default	Fee Schedule	96.37				33.5	203.22
THER / PROPH / DIAG INJ IN PUSH	96374	HCPCS	260	RC		both	209.5	178.08	Medicare A ID JF	Default	Other	81.71		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	33.5	203.22
THER / PROPH / DIAG INJ IN PUSH	96374	HCPCS	260	RC		both	209.5	178.08	Medicare B ID JF	Default	Fee Schedule	33.5		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		33.5	203.22
THER / PROPH / DIAG INJ IN PUSH	96374	HCPCS	260	RC		both	209.5	178.08	Regence Group Administrators	Default	Fee Schedule	203.22				33.5	203.22
THER / PROPH / DIAG INJ IN PUSH	96374	HCPCS	260	RC		both	209.5	178.08	SelectHealth	Default	Percent of Total Billed Charges	199.02				33.5	203.22
THER / PROPH / DIAG INJ IN PUSH	96374	HCPCS	260	RC	59	both	209.5	178.08	Blue Cross of ID	Default	Percent of Total Billed Charges	203.22				33.5	203.22
THER / PROPH / DIAG INJ IN PUSH	96374	HCPCS	260	RC	59	both	209.5	178.08	Medicaid Idaho	Default	Fee Schedule	96.37				33.5	203.22
THER / PROPH / DIAG INJ IN PUSH	96374	HCPCS	260	RC	59	both	209.5	178.08	Medicare A ID JF	Default	Other	81.71		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	33.5	203.22
THER / PROPH / DIAG INJ IN PUSH	96374	HCPCS	260	RC	59	both	209.5	178.08	Medicare B ID JF	Default	Fee Schedule	33.5		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		33.5	203.22
THER / PROPH / DIAG INJ IN PUSH	96374	HCPCS	260	RC	59	both	209.5	178.08	Regence Group Administrators	Default	Fee Schedule	203.22				33.5	203.22
THER / PROPH / DIAG INJ IN PUSH	96374	HCPCS	260	RC	59	both	209.5	178.08	SelectHealth	Default	Percent of Total Billed Charges	199.02				33.5	203.22
TX /PRO/ DX INJ NEW DRUG ADD-ON	96375	HCPCS	260	RC		both	171.5	145.78	Blue Cross of ID	Default	Percent of Total Billed Charges	166.36				14.06	166.36
TX /PRO/ DX INJ NEW DRUG ADD-ON	96375	HCPCS	260	RC		both	171.5	145.78	Medicaid Idaho	Default	Fee Schedule	78.89				14.06	166.36
TX /PRO/ DX INJ NEW DRUG ADD-ON	96375	HCPCS	260	RC		both	171.5	145.78	Medicare A ID JF	Default	Other	66.89		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	14.06	166.36
TX /PRO/ DX INJ NEW DRUG ADD-ON	96375	HCPCS	260	RC		both	171.5	145.78	Medicare B ID JF	Default	Fee Schedule	14.06		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		14.06	166.36
TX /PRO/ DX INJ NEW DRUG ADD-ON	96375	HCPCS	260	RC		both	171.5	145.78	Regence Group Administrators	Default	Fee Schedule	166.36				14.06	166.36
TX /PRO/ DX INJ NEW DRUG ADD-ON	96375	HCPCS	260	RC		both	171.5	145.78	SelectHealth	Default	Percent of Total Billed Charges	162.92				14.06	166.36
TX /PRO/ DX INJ NEW DRUG ADD-ON	96375	HCPCS	260	RC	59	both	171.5	145.78	Blue Cross of ID	Default	Percent of Total Billed Charges	166.36				14.06	166.36
TX /PRO/ DX INJ NEW DRUG ADD-ON	96375	HCPCS	260	RC	59	both	171.5	145.78	Medicaid Idaho	Default	Fee Schedule	78.89				14.06	166.36
TX /PRO/ DX INJ NEW DRUG ADD-ON	96375	HCPCS	260	RC	59	both	171.5	145.78	Medicare A ID JF	Default	Other	66.89		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	14.06	166.36
TX /PRO/ DX INJ NEW DRUG ADD-ON	96375	HCPCS	260	RC	59	both	171.5	145.78	Medicare B ID JF	Default	Fee Schedule	14.06		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		14.06	166.36
TX /PRO/ DX INJ NEW DRUG ADD-ON	96375	HCPCS	260	RC	59	both	171.5	145.78	Regence Group Administrators	Default	Fee Schedule	166.36				14.06	166.36
TX /PRO/ DX INJ NEW DRUG ADD-ON	96375	HCPCS	260	RC	59	both	171.5	145.78	SelectHealth	Default	Percent of Total Billed Charges	162.92				14.06	166.36
TX / PRO/ DX INJ SAME DRUG ADD-ON	96376	HCPCS	260	RC		both	150.5	127.93	Blue Cross of ID	Default	Percent of Total Billed Charges	145.98				58.7	145.98
TX / PRO/ DX INJ SAME DRUG ADD-ON	96376	HCPCS	260	RC		both	150.5	127.93	Medicaid Idaho	Default	Fee Schedule	69.23				58.7	145.98
TX / PRO/ DX INJ SAME DRUG ADD-ON	96376	HCPCS	260	RC		both	150.5	127.93	Medicare A ID JF	Default	Other	58.7		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	58.7	145.98
TX / PRO/ DX INJ SAME DRUG ADD-ON	96376	HCPCS	260	RC		both	150.5	127.93	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		58.7	145.98
TX / PRO/ DX INJ SAME DRUG ADD-ON	96376	HCPCS	260	RC		both	150.5	127.93	Regence Group Administrators	Default	Fee Schedule	145.98				58.7	145.98
TX / PRO/ DX INJ SAME DRUG ADD-ON	96376	HCPCS	260	RC		both	150.5	127.93	SelectHealth	Default	Percent of Total Billed Charges	142.98				58.7	145.98
TX / PRO/ DX INJ SAME DRUG ADD-ON	96376	HCPCS	260	RC	59	both	150.5	127.93	Blue Cross of ID	Default	Percent of Total Billed Charges	145.98				58.7	145.98
TX / PRO/ DX INJ SAME DRUG ADD-ON	96376	HCPCS	260	RC	59	both	150.5	127.93	Medicaid Idaho	Default	Fee Schedule	69.23				58.7	145.98
TX / PRO/ DX INJ SAME DRUG ADD-ON	96376	HCPCS	260	RC	59	both	150.5	127.93	Medicare A ID JF	Default	Other	58.7		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	58.7	145.98
TX / PRO/ DX INJ SAME DRUG ADD-ON	96376	HCPCS	260	RC	59	both	150.5	127.93	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		58.7	145.98
TX / PRO/ DX INJ SAME DRUG ADD-ON	96376	HCPCS	260	RC	59	both	150.5	127.93	Regence Group Administrators	Default	Fee Schedule	145.98				58.7	145.98
TX / PRO/ DX INJ SAME DRUG ADD-ON	96376	HCPCS	260	RC	59	both	150.5	127.93	SelectHealth	Default	Percent of Total Billed Charges	142.98				58.7	145.98
CHEMO ANTI-NEOPL SQ/ IM	96401	HCPCS	280	RC		both	232.5	197.63	Blue Cross of ID	Default	Percent of Total Billed Charges	225.52				65.03	225.52
CHEMO ANTI-NEOPL SQ/ IM	96401	HCPCS	280	RC		both	232.5	197.63	Medicaid Idaho	Default	Fee Schedule	106.95				65.03	225.52
CHEMO ANTI-NEOPL SQ/ IM	96401	HCPCS	280	RC		both	232.5	197.63	Medicare A ID JF	Default	Other	90.68		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	65.03	225.52
CHEMO ANTI-NEOPL SQ/ IM	96401	HCPCS	280	RC		both	232.5	197.63	Medicare B ID JF	Default	Fee Schedule	65.03		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		65.03	225.52
CHEMO ANTI-NEOPL SQ/ IM	96401	HCPCS	280	RC		both	232.5	197.63	Regence Group Administrators	Default	Fee Schedule	225.52				65.03	225.52
CHEMO ANTI-NEOPL SQ/ IM	96401	HCPCS	280	RC		both	232.5	197.63	SelectHealth	Default	Percent of Total Billed Charges	220.88				65.03	225.52
CHEMO HORMON ANTINEOPL SQ/ IM	96402	HCPCS	280	RC		both	194	164.9	Blue Cross of ID	Default	Percent of Total Billed Charges	188.18				32.32	188.18
CHEMO HORMON ANTINEOPL SQ/ IM	96402	HCPCS	280	RC		both	194	164.9	Medicaid Idaho	Default	Fee Schedule	89.24				32.32	188.18
CHEMO HORMON ANTINEOPL SQ/ IM	96402	HCPCS	280	RC		both	194	164.9	Medicare A ID JF	Default	Other	75.66		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	32.32	188.18
CHEMO HORMON ANTINEOPL SQ/ IM	96402	HCPCS	280	RC		both	194	164.9	Medicare B ID JF	Default	Fee Schedule	32.32		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		32.32	188.18
CHEMO HORMON ANTINEOPL SQ/ IM	96402	HCPCS	280	RC		both	194	164.9	Regence Group Administrators	Default	Fee Schedule	188.18				32.32	188.18
CHEMO HORMON ANTINEOPL SQ/ IM	96402	HCPCS	280	RC		both	194	164.9	SelectHealth	Default	Percent of Total Billed Charges	184.3				32.32	188.18
CHEMO IV PUSH SNGL DRUG	96409	HCPCS	280	RC		both	365	310.25	Blue Cross of ID	Default	Percent of Total Billed Charges	354.05				90.52	354.05
CHEMO IV PUSH SNGL DRUG	96409	HCPCS	280	RC		both	365	310.25	Medicaid Idaho	Default	Fee Schedule	167.9				90.52	354.05
CHEMO IV PUSH SNGL DRUG	96409	HCPCS	280	RC		both	365	310.25	Medicare A ID JF	Default	Other	142.35		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	90.52	354.05
CHEMO IV PUSH SNGL DRUG	96409	HCPCS	280	RC		both	365	310.25	Medicare B ID JF	Default	Fee Schedule	90.52		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		90.52	354.05
CHEMO IV PUSH SNGL DRUG	96409	HCPCS	280	RC		both	365	310.25	Regence Group Administrators	Default	Fee Schedule	354.05				90.52	354.05
CHEMO IV PUSH SNGL DRUG	96409	HCPCS	280	RC		both	365	310.25	SelectHealth	Default	Percent of Total Billed Charges	346.75				90.52	354.05
CHEMO IV PUSH ADDL DRUG	96411	HCPCS	280	RC		both	273	232.05	Blue Cross of ID	Default	Percent of Total Billed Charges	264.81				49.43	264.81
CHEMO IV PUSH ADDL DRUG	96411	HCPCS	280	RC		both	273	232.05	Medicaid Idaho	Default	Fee Schedule	125.58				49.43	264.81
CHEMO IV PUSH ADDL DRUG	96411	HCPCS	280	RC		both	273	232.05	Medicare A ID JF	Default	Other	106.47		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	49.43	264.81
CHEMO IV PUSH ADDL DRUG	96411	HCPCS	280	RC		both	273	232.05	Medicare B ID JF	Default	Fee Schedule	49.43		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		49.43	264.81
CHEMO IV PUSH ADDL DRUG	96411	HCPCS	280	RC		both	273	232.05	Regence Group Administrators	Default	Fee Schedule	264.81				49.43	264.81
CHEMO IV PUSH ADDL DRUG	96411	HCPCS	280	RC		both	273	232.05	SelectHealth	Default	Percent of Total Billed Charges	259.35				49.43	264.81
CHEMO IV INFUSION 1 HR	96413	HCPCS	280	RC		both	639	543.15	Blue Cross of ID	Default	Percent of Total Billed Charges	619.83				117.09	619.83
CHEMO IV INFUSION 1 HR	96413	HCPCS	280	RC		both	639	543.15	Medicaid Idaho	Default	Fee Schedule	293.94				117.09	619.83
CHEMO IV INFUSION 1 HR	96413	HCPCS	280	RC		both	639	543.15	Medicare A ID JF	Default	Other	249.21		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	117.09	619.83
CHEMO IV INFUSION 1 HR	96413	HCPCS	280	RC		both	639	543.15	Medicare B ID JF	Default	Fee Schedule	117.09		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		117.09	619.83
CHEMO IV INFUSION 1 HR	96413	HCPCS	280	RC		both	639	543.15	Regence Group Administrators	Default	Fee Schedule	619.83				117.09	619.83
CHEMO IV INFUSION 1 HR	96413	HCPCS	280	RC		both	639	543.15	SelectHealth	Default	Percent of Total Billed Charges	607.05				117.09	619.83
CHEMO IV INFUSION ADDL HR	96415	HCPCS	280	RC		both	206	175.1	Blue Cross of ID	Default	Percent of Total Billed Charges	199.82				25.37	199.82
CHEMO IV INFUSION ADDL HR	96415	HCPCS	280	RC		both	206	175.1	Medicaid Idaho	Default	Fee Schedule	94.76				25.37	199.82
CHEMO IV INFUSION ADDL HR	96415	HCPCS	280	RC		both	206	175.1	Medicare A ID JF	Default	Other	80.34		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	25.37	199.82
CHEMO IV INFUSION ADDL HR	96415	HCPCS	280	RC		both	206	175.1	Medicare B ID JF	Default	Fee Schedule	25.37		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		25.37	199.82
CHEMO IV INFUSION ADDL HR	96415	HCPCS	280	RC		both	206	175.1	Regence Group Administrators	Default	Fee Schedule	199.82				25.37	199.82
CHEMO IV INFUSION ADDL HR	96415	HCPCS	280	RC		both	206	175.1	SelectHealth	Default	Percent of Total Billed Charges	195.7				25.37	199.82
CHEMO IV INFUS EACH ADDL SEQ	96417	HCPCS	280	RC		both	269.5	229.08	Blue Cross of ID	Default	Percent of Total Billed Charges	261.42				57.78	261.42
CHEMO IV INFUS EACH ADDL SEQ	96417	HCPCS	280	RC		both	269.5	229.08	Medicaid Idaho	Default	Fee Schedule	123.97				57.78	261.42
CHEMO IV INFUS EACH ADDL SEQ	96417	HCPCS	280	RC		both	269.5	229.08	Medicare A ID JF	Default	Other	105.11		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	57.78	261.42
CHEMO IV INFUS EACH ADDL SEQ	96417	HCPCS	280	RC		both	269.5	229.08	Medicare B ID JF	Default	Fee Schedule	57.78		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		57.78	261.42
CHEMO IV INFUS EACH ADDL SEQ	96417	HCPCS	280	RC		both	269.5	229.08	Regence Group Administrators	Default	Fee Schedule	261.42				57.78	261.42
CHEMO IV INFUS EACH ADDL SEQ	96417	HCPCS	280	RC		both	269.5	229.08	SelectHealth	Default	Percent of Total Billed Charges	256.02				57.78	261.42
REFILL/ MAINT PORTABLE PUMP	96521	HCPCS	280	RC		both	400	340	Blue Cross of ID	Default	Percent of Total Billed Charges	388				112.04	388
REFILL/ MAINT PORTABLE PUMP	96521	HCPCS	280	RC		both	400	340	Medicaid Idaho	Default	Fee Schedule	184				112.04	388
REFILL/ MAINT PORTABLE PUMP	96521	HCPCS	280	RC		both	400	340	Medicare A ID JF	Default	Other	156		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	112.04	388
REFILL/ MAINT PORTABLE PUMP	96521	HCPCS	280	RC		both	400	340	Medicare B ID JF	Default	Fee Schedule	112.04		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		112.04	388
REFILL/ MAINT PORTABLE PUMP	96521	HCPCS	280	RC		both	400	340	Regence Group Administrators	Default	Fee Schedule	388				112.04	388
REFILL/ MAINT PORTABLE PUMP	96521	HCPCS	280	RC		both	400	340	SelectHealth	Default	Percent of Total Billed Charges	380				112.04	388
REFILL/MAINT PUMP/ RESVR SYST	96522	HCPCS	280	RC		both	416	353.6	Blue Cross of ID	Default	Percent of Total Billed Charges	403.52				106.3	403.52
REFILL/MAINT PUMP/ RESVR SYST	96522	HCPCS	280	RC		both	416	353.6	Medicaid Idaho	Default	Fee Schedule	191.36				106.3	403.52
REFILL/MAINT PUMP/ RESVR SYST	96522	HCPCS	280	RC		both	416	353.6	Medicare A ID JF	Default	Other	162.24		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	106.3	403.52
REFILL/MAINT PUMP/ RESVR SYST	96522	HCPCS	280	RC		both	416	353.6	Medicare B ID JF	Default	Fee Schedule	106.3		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		106.3	403.52
REFILL/MAINT PUMP/ RESVR SYST	96522	HCPCS	280	RC		both	416	353.6	Regence Group Administrators	Default	Fee Schedule	403.52				106.3	403.52
REFILL/MAINT PUMP/ RESVR SYST	96522	HCPCS	280	RC		both	416	353.6	SelectHealth	Default	Percent of Total Billed Charges	395.2				106.3	403.52
IRRIG DRUG DELIVERY DEVICE	96523	HCPCS	280	RC		both	151.5	128.78	Blue Cross of ID	Default	Percent of Total Billed Charges	146.96				22.64	146.96
IRRIG DRUG DELIVERY DEVICE	96523	HCPCS	280	RC		both	151.5	128.78	Medicaid Idaho	Default	Fee Schedule	69.69				22.64	146.96
IRRIG DRUG DELIVERY DEVICE	96523	HCPCS	280	RC		both	151.5	128.78	Medicare A ID JF	Default	Other	59.09		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	22.64	146.96
IRRIG DRUG DELIVERY DEVICE	96523	HCPCS	280	RC		both	151.5	128.78	Medicare B ID JF	Default	Fee Schedule	22.64		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		22.64	146.96
IRRIG DRUG DELIVERY DEVICE	96523	HCPCS	280	RC		both	151.5	128.78	Regence Group Administrators	Default	Fee Schedule	146.96				22.64	146.96
IRRIG DRUG DELIVERY DEVICE	96523	HCPCS	280	RC		both	151.5	128.78	SelectHealth	Default	Percent of Total Billed Charges	143.92				22.64	146.96
CHEMOTHERAPY UNSPECIFIED	96549	HCPCS	280	RC		both	120.5	102.43	Blue Cross of ID	Default	Percent of Total Billed Charges	116.88				47	116.88
CHEMOTHERAPY UNSPECIFIED	96549	HCPCS	280	RC		both	120.5	102.43	Medicaid Idaho	Default	Fee Schedule	55.43				47	116.88
CHEMOTHERAPY UNSPECIFIED	96549	HCPCS	280	RC		both	120.5	102.43	Medicare A ID JF	Default	Other	47		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	47	116.88
CHEMOTHERAPY UNSPECIFIED	96549	HCPCS	280	RC		both	120.5	102.43	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		47	116.88
CHEMOTHERAPY UNSPECIFIED	96549	HCPCS	280	RC		both	120.5	102.43	Regence Group Administrators	Default	Fee Schedule	116.88				47	116.88
CHEMOTHERAPY UNSPECIFIED	96549	HCPCS	280	RC		both	120.5	102.43	SelectHealth	Default	Percent of Total Billed Charges	114.48				47	116.88
NAIL REMOVAL SINGLE	11730	HCPCS	450	RC		outpatient	278.5	236.73	Blue Cross of ID	Default	Percent of Total Billed Charges	270.14				106.46	270.14
NAIL REMOVAL SINGLE	11730	HCPCS	450	RC		outpatient	278.5	236.73	Medicaid Idaho	Default	Fee Schedule	128.11				106.46	270.14
NAIL REMOVAL SINGLE	11730	HCPCS	450	RC		outpatient	278.5	236.73	Medicare A ID JF	Default	Other	108.62		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	106.46	270.14
NAIL REMOVAL SINGLE	11730	HCPCS	450	RC		outpatient	278.5	236.73	Medicare B ID JF	Default	Fee Schedule	106.46		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		106.46	270.14
NAIL REMOVAL SINGLE	11730	HCPCS	450	RC		outpatient	278.5	236.73	Regence Group Administrators	Default	Fee Schedule	270.14				106.46	270.14
NAIL REMOVAL SINGLE	11730	HCPCS	450	RC		outpatient	278.5	236.73	SelectHealth	Default	Percent of Total Billed Charges	264.58				106.46	270.14
NAIL REMOVAL EA ADDITIONAL	11732	HCPCS	450	RC		outpatient	208	176.8	Blue Cross of ID	Default	Percent of Total Billed Charges	201.76				30.64	201.76
NAIL REMOVAL EA ADDITIONAL	11732	HCPCS	450	RC		outpatient	208	176.8	Medicaid Idaho	Default	Fee Schedule	95.68				30.64	201.76
NAIL REMOVAL EA ADDITIONAL	11732	HCPCS	450	RC		outpatient	208	176.8	Medicare A ID JF	Default	Other	81.12		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	30.64	201.76
NAIL REMOVAL EA ADDITIONAL	11732	HCPCS	450	RC		outpatient	208	176.8	Medicare B ID JF	Default	Fee Schedule	30.64		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		30.64	201.76
NAIL REMOVAL EA ADDITIONAL	11732	HCPCS	450	RC		outpatient	208	176.8	Regence Group Administrators	Default	Fee Schedule	201.76				30.64	201.76
NAIL REMOVAL EA ADDITIONAL	11732	HCPCS	450	RC		outpatient	208	176.8	SelectHealth	Default	Percent of Total Billed Charges	197.6				30.64	201.76
DRAIN BLOOD UNDER NAIL	11740	HCPCS	450	RC		outpatient	209.5	178.08	Blue Cross of ID	Default	Percent of Total Billed Charges	203.22				53.28	203.22
DRAIN BLOOD UNDER NAIL	11740	HCPCS	450	RC		outpatient	209.5	178.08	Medicaid Idaho	Default	Fee Schedule	96.37				53.28	203.22
DRAIN BLOOD UNDER NAIL	11740	HCPCS	450	RC		outpatient	209.5	178.08	Medicare A ID JF	Default	Other	81.71		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	53.28	203.22
DRAIN BLOOD UNDER NAIL	11740	HCPCS	450	RC		outpatient	209.5	178.08	Medicare B ID JF	Default	Fee Schedule	53.28		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		53.28	203.22
DRAIN BLOOD UNDER NAIL	11740	HCPCS	450	RC		outpatient	209.5	178.08	Regence Group Administrators	Default	Fee Schedule	203.22				53.28	203.22
DRAIN BLOOD UNDER NAIL	11740	HCPCS	450	RC		outpatient	209.5	178.08	SelectHealth	Default	Percent of Total Billed Charges	199.02				53.28	203.22
"REMOVAL OF NAIL BED, PERMANENT"	11750	HCPCS	450	RC		outpatient	720	612	Blue Cross of ID	Default	Percent of Total Billed Charges	698.4				149.19	698.4
"REMOVAL OF NAIL BED, PERMANENT"	11750	HCPCS	450	RC		outpatient	720	612	Medicaid Idaho	Default	Fee Schedule	331.2				149.19	698.4
"REMOVAL OF NAIL BED, PERMANENT"	11750	HCPCS	450	RC		outpatient	720	612	Medicare A ID JF	Default	Other	280.8		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	149.19	698.4
"REMOVAL OF NAIL BED, PERMANENT"	11750	HCPCS	450	RC		outpatient	720	612	Medicare B ID JF	Default	Fee Schedule	149.19		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		149.19	698.4
"REMOVAL OF NAIL BED, PERMANENT"	11750	HCPCS	450	RC		outpatient	720	612	Regence Group Administrators	Default	Fee Schedule	698.4				149.19	698.4
"REMOVAL OF NAIL BED, PERMANENT"	11750	HCPCS	450	RC		outpatient	720	612	SelectHealth	Default	Percent of Total Billed Charges	684				149.19	698.4
WEDGE EXCISION NAIL FOLD TOE	11765	HCPCS	450	RC		outpatient	370.5	314.93	Blue Cross of ID	Default	Percent of Total Billed Charges	359.38				144.5	359.38
WEDGE EXCISION NAIL FOLD TOE	11765	HCPCS	450	RC		outpatient	370.5	314.93	Medicaid Idaho	Default	Fee Schedule	170.43				144.5	359.38
WEDGE EXCISION NAIL FOLD TOE	11765	HCPCS	450	RC		outpatient	370.5	314.93	Medicare A ID JF	Default	Other	144.5		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	144.5	359.38
WEDGE EXCISION NAIL FOLD TOE	11765	HCPCS	450	RC		outpatient	370.5	314.93	Medicare B ID JF	Default	Fee Schedule	153.37		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		144.5	359.38
WEDGE EXCISION NAIL FOLD TOE	11765	HCPCS	450	RC		outpatient	370.5	314.93	Regence Group Administrators	Default	Fee Schedule	359.38				144.5	359.38
WEDGE EXCISION NAIL FOLD TOE	11765	HCPCS	450	RC		outpatient	370.5	314.93	SelectHealth	Default	Percent of Total Billed Charges	351.98				144.5	359.38
LAC SIMPLE <2.5	12001	HCPCS	450	RC		outpatient	352.5	299.63	Blue Cross of ID	Default	Percent of Total Billed Charges	341.92				86.03	341.92
LAC SIMPLE <2.5	12001	HCPCS	450	RC		outpatient	352.5	299.63	Medicaid Idaho	Default	Fee Schedule	162.15				86.03	341.92
LAC SIMPLE <2.5	12001	HCPCS	450	RC		outpatient	352.5	299.63	Medicare A ID JF	Default	Other	137.48		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	86.03	341.92
LAC SIMPLE <2.5	12001	HCPCS	450	RC		outpatient	352.5	299.63	Medicare B ID JF	Default	Fee Schedule	86.03		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		86.03	341.92
LAC SIMPLE <2.5	12001	HCPCS	450	RC		outpatient	352.5	299.63	Regence Group Administrators	Default	Fee Schedule	341.92				86.03	341.92
LAC SIMPLE <2.5	12001	HCPCS	450	RC		outpatient	352.5	299.63	SelectHealth	Default	Percent of Total Billed Charges	334.88				86.03	341.92
LAC SIMPLE 2.6 TO 7.5	12002	HCPCS	450	RC		outpatient	401	340.85	Blue Cross of ID	Default	Percent of Total Billed Charges	388.97				104.19	388.97
LAC SIMPLE 2.6 TO 7.5	12002	HCPCS	450	RC		outpatient	401	340.85	Medicaid Idaho	Default	Fee Schedule	184.46				104.19	388.97
LAC SIMPLE 2.6 TO 7.5	12002	HCPCS	450	RC		outpatient	401	340.85	Medicare A ID JF	Default	Other	156.39		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	104.19	388.97
LAC SIMPLE 2.6 TO 7.5	12002	HCPCS	450	RC		outpatient	401	340.85	Medicare B ID JF	Default	Fee Schedule	104.19		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		104.19	388.97
LAC SIMPLE 2.6 TO 7.5	12002	HCPCS	450	RC		outpatient	401	340.85	Regence Group Administrators	Default	Fee Schedule	388.97				104.19	388.97
LAC SIMPLE 2.6 TO 7.5	12002	HCPCS	450	RC		outpatient	401	340.85	SelectHealth	Default	Percent of Total Billed Charges	380.95				104.19	388.97
LAC SIMPLE 7.6 TO 12.5	12004	HCPCS	450	RC		outpatient	539.5	458.58	Blue Cross of ID	Default	Percent of Total Billed Charges	523.32				121.3	523.32
LAC SIMPLE 7.6 TO 12.5	12004	HCPCS	450	RC		outpatient	539.5	458.58	Medicaid Idaho	Default	Fee Schedule	248.17				121.3	523.32
LAC SIMPLE 7.6 TO 12.5	12004	HCPCS	450	RC		outpatient	539.5	458.58	Medicare A ID JF	Default	Other	210.41		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	121.3	523.32
LAC SIMPLE 7.6 TO 12.5	12004	HCPCS	450	RC		outpatient	539.5	458.58	Medicare B ID JF	Default	Fee Schedule	121.3		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		121.3	523.32
LAC SIMPLE 7.6 TO 12.5	12004	HCPCS	450	RC		outpatient	539.5	458.58	Regence Group Administrators	Default	Fee Schedule	523.32				121.3	523.32
LAC SIMPLE 7.6 TO 12.5	12004	HCPCS	450	RC		outpatient	539.5	458.58	SelectHealth	Default	Percent of Total Billed Charges	512.52				121.3	523.32
LAC SIMPLE 12.6 TO 20	12005	HCPCS	450	RC		outpatient	547.5	465.38	Blue Cross of ID	Default	Percent of Total Billed Charges	531.08				161.48	531.08
LAC SIMPLE 12.6 TO 20	12005	HCPCS	450	RC		outpatient	547.5	465.38	Medicaid Idaho	Default	Fee Schedule	251.85				161.48	531.08
LAC SIMPLE 12.6 TO 20	12005	HCPCS	450	RC		outpatient	547.5	465.38	Medicare A ID JF	Default	Other	213.53		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	161.48	531.08
LAC SIMPLE 12.6 TO 20	12005	HCPCS	450	RC		outpatient	547.5	465.38	Medicare B ID JF	Default	Fee Schedule	161.48		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		161.48	531.08
LAC SIMPLE 12.6 TO 20	12005	HCPCS	450	RC		outpatient	547.5	465.38	Regence Group Administrators	Default	Fee Schedule	531.08				161.48	531.08
LAC SIMPLE 12.6 TO 20	12005	HCPCS	450	RC		outpatient	547.5	465.38	SelectHealth	Default	Percent of Total Billed Charges	520.12				161.48	531.08
LAC SIMPLE 20.1 TO 30	12006	HCPCS	450	RC		outpatient	760	646	Blue Cross of ID	Default	Percent of Total Billed Charges	737.2				186.51	737.2
LAC SIMPLE 20.1 TO 30	12006	HCPCS	450	RC		outpatient	760	646	Medicaid Idaho	Default	Fee Schedule	349.6				186.51	737.2
LAC SIMPLE 20.1 TO 30	12006	HCPCS	450	RC		outpatient	760	646	Medicare A ID JF	Default	Other	296.4		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	186.51	737.2
LAC SIMPLE 20.1 TO 30	12006	HCPCS	450	RC		outpatient	760	646	Medicare B ID JF	Default	Fee Schedule	186.51		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		186.51	737.2
LAC SIMPLE 20.1 TO 30	12006	HCPCS	450	RC		outpatient	760	646	Regence Group Administrators	Default	Fee Schedule	737.2				186.51	737.2
LAC SIMPLE 20.1 TO 30	12006	HCPCS	450	RC		outpatient	760	646	SelectHealth	Default	Percent of Total Billed Charges	722				186.51	737.2
LAC SIMPLE OVER 30	12007	HCPCS	450	RC		outpatient	1071.5	910.78	Blue Cross of ID	Default	Percent of Total Billed Charges	1039.36				211.52	1039.36
LAC SIMPLE OVER 30	12007	HCPCS	450	RC		outpatient	1071.5	910.78	Medicaid Idaho	Default	Fee Schedule	492.89				211.52	1039.36
LAC SIMPLE OVER 30	12007	HCPCS	450	RC		outpatient	1071.5	910.78	Medicare A ID JF	Default	Other	417.89		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	211.52	1039.36
LAC SIMPLE OVER 30	12007	HCPCS	450	RC		outpatient	1071.5	910.78	Medicare B ID JF	Default	Fee Schedule	211.52		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		211.52	1039.36
LAC SIMPLE OVER 30	12007	HCPCS	450	RC		outpatient	1071.5	910.78	Regence Group Administrators	Default	Fee Schedule	1039.36				211.52	1039.36
LAC SIMPLE OVER 30	12007	HCPCS	450	RC		outpatient	1071.5	910.78	SelectHealth	Default	Percent of Total Billed Charges	1017.92				211.52	1039.36
LAC FACE/EAR SIMPLE <2.5 CM	12011	HCPCS	450	RC		outpatient	347.5	295.38	Blue Cross of ID	Default	Percent of Total Billed Charges	337.08				102.31	337.08
LAC FACE/EAR SIMPLE <2.5 CM	12011	HCPCS	450	RC		outpatient	347.5	295.38	Medicaid Idaho	Default	Fee Schedule	159.85				102.31	337.08
LAC FACE/EAR SIMPLE <2.5 CM	12011	HCPCS	450	RC		outpatient	347.5	295.38	Medicare A ID JF	Default	Other	135.53		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	102.31	337.08
LAC FACE/EAR SIMPLE <2.5 CM	12011	HCPCS	450	RC		outpatient	347.5	295.38	Medicare B ID JF	Default	Fee Schedule	102.31		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		102.31	337.08
LAC FACE/EAR SIMPLE <2.5 CM	12011	HCPCS	450	RC		outpatient	347.5	295.38	Regence Group Administrators	Default	Fee Schedule	337.08				102.31	337.08
LAC FACE/EAR SIMPLE <2.5 CM	12011	HCPCS	450	RC		outpatient	347.5	295.38	SelectHealth	Default	Percent of Total Billed Charges	330.12				102.31	337.08
LAC FACE/EAR SIMPLE 2.6-5CM	12013	HCPCS	450	RC		outpatient	387.5	329.38	Blue Cross of ID	Default	Percent of Total Billed Charges	375.88				106.56	375.88
LAC FACE/EAR SIMPLE 2.6-5CM	12013	HCPCS	450	RC		outpatient	387.5	329.38	Medicaid Idaho	Default	Fee Schedule	178.25				106.56	375.88
LAC FACE/EAR SIMPLE 2.6-5CM	12013	HCPCS	450	RC		outpatient	387.5	329.38	Medicare A ID JF	Default	Other	151.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	106.56	375.88
LAC FACE/EAR SIMPLE 2.6-5CM	12013	HCPCS	450	RC		outpatient	387.5	329.38	Medicare B ID JF	Default	Fee Schedule	106.56		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		106.56	375.88
LAC FACE/EAR SIMPLE 2.6-5CM	12013	HCPCS	450	RC		outpatient	387.5	329.38	Regence Group Administrators	Default	Fee Schedule	375.88				106.56	375.88
LAC FACE/EAR SIMPLE 2.6-5CM	12013	HCPCS	450	RC		outpatient	387.5	329.38	SelectHealth	Default	Percent of Total Billed Charges	368.12				106.56	375.88
LAC FACE/EAR SIMPLE 5.1-7.5CM	12014	HCPCS	450	RC		outpatient	543.5	461.98	Blue Cross of ID	Default	Percent of Total Billed Charges	527.2				130.01	527.2
LAC FACE/EAR SIMPLE 5.1-7.5CM	12014	HCPCS	450	RC		outpatient	543.5	461.98	Medicaid Idaho	Default	Fee Schedule	250.01				130.01	527.2
LAC FACE/EAR SIMPLE 5.1-7.5CM	12014	HCPCS	450	RC		outpatient	543.5	461.98	Medicare A ID JF	Default	Other	211.97		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	130.01	527.2
LAC FACE/EAR SIMPLE 5.1-7.5CM	12014	HCPCS	450	RC		outpatient	543.5	461.98	Medicare B ID JF	Default	Fee Schedule	130.01		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		130.01	527.2
LAC FACE/EAR SIMPLE 5.1-7.5CM	12014	HCPCS	450	RC		outpatient	543.5	461.98	Regence Group Administrators	Default	Fee Schedule	527.2				130.01	527.2
LAC FACE/EAR SIMPLE 5.1-7.5CM	12014	HCPCS	450	RC		outpatient	543.5	461.98	SelectHealth	Default	Percent of Total Billed Charges	516.32				130.01	527.2
LAC FACE/EAR SIMPLE 7.6-12.5CM	12015	HCPCS	450	RC		outpatient	563	478.55	Blue Cross of ID	Default	Percent of Total Billed Charges	546.11				156.98	546.11
LAC FACE/EAR SIMPLE 7.6-12.5CM	12015	HCPCS	450	RC		outpatient	563	478.55	Medicaid Idaho	Default	Fee Schedule	258.98				156.98	546.11
LAC FACE/EAR SIMPLE 7.6-12.5CM	12015	HCPCS	450	RC		outpatient	563	478.55	Medicare A ID JF	Default	Other	219.57		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	156.98	546.11
LAC FACE/EAR SIMPLE 7.6-12.5CM	12015	HCPCS	450	RC		outpatient	563	478.55	Medicare B ID JF	Default	Fee Schedule	156.98		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		156.98	546.11
LAC FACE/EAR SIMPLE 7.6-12.5CM	12015	HCPCS	450	RC		outpatient	563	478.55	Regence Group Administrators	Default	Fee Schedule	546.11				156.98	546.11
LAC FACE/EAR SIMPLE 7.6-12.5CM	12015	HCPCS	450	RC		outpatient	563	478.55	SelectHealth	Default	Percent of Total Billed Charges	534.85				156.98	546.11
LAC FACE/EAR SIMPLE 12.6-20CM	12016	HCPCS	450	RC		outpatient	579	492.15	Blue Cross of ID	Default	Percent of Total Billed Charges	561.63				199.05	561.63
LAC FACE/EAR SIMPLE 12.6-20CM	12016	HCPCS	450	RC		outpatient	579	492.15	Medicaid Idaho	Default	Fee Schedule	266.34				199.05	561.63
LAC FACE/EAR SIMPLE 12.6-20CM	12016	HCPCS	450	RC		outpatient	579	492.15	Medicare A ID JF	Default	Other	225.81		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	199.05	561.63
LAC FACE/EAR SIMPLE 12.6-20CM	12016	HCPCS	450	RC		outpatient	579	492.15	Medicare B ID JF	Default	Fee Schedule	199.05		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		199.05	561.63
LAC FACE/EAR SIMPLE 12.6-20CM	12016	HCPCS	450	RC		outpatient	579	492.15	Regence Group Administrators	Default	Fee Schedule	561.63				199.05	561.63
LAC FACE/EAR SIMPLE 12.6-20CM	12016	HCPCS	450	RC		outpatient	579	492.15	SelectHealth	Default	Percent of Total Billed Charges	550.05				199.05	561.63
LAC FACE/EAR SIMPLE 20.1-30CM	12017	HCPCS	450	RC		outpatient	601.5	511.28	Blue Cross of ID	Default	Percent of Total Billed Charges	583.46				138.51	583.46
LAC FACE/EAR SIMPLE 20.1-30CM	12017	HCPCS	450	RC		outpatient	601.5	511.28	Medicaid Idaho	Default	Fee Schedule	276.69				138.51	583.46
LAC FACE/EAR SIMPLE 20.1-30CM	12017	HCPCS	450	RC		outpatient	601.5	511.28	Medicare A ID JF	Default	Other	234.59		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	138.51	583.46
LAC FACE/EAR SIMPLE 20.1-30CM	12017	HCPCS	450	RC		outpatient	601.5	511.28	Medicare B ID JF	Default	Fee Schedule	138.51		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		138.51	583.46
LAC FACE/EAR SIMPLE 20.1-30CM	12017	HCPCS	450	RC		outpatient	601.5	511.28	Regence Group Administrators	Default	Fee Schedule	583.46				138.51	583.46
LAC FACE/EAR SIMPLE 20.1-30CM	12017	HCPCS	450	RC		outpatient	601.5	511.28	SelectHealth	Default	Percent of Total Billed Charges	571.42				138.51	583.46
LAC FACE/EAR SIMPLE >30	12018	HCPCS	450	RC		outpatient	718.5	610.73	Blue Cross of ID	Default	Percent of Total Billed Charges	696.94				156.16	696.94
LAC FACE/EAR SIMPLE >30	12018	HCPCS	450	RC		outpatient	718.5	610.73	Medicaid Idaho	Default	Fee Schedule	330.51				156.16	696.94
LAC FACE/EAR SIMPLE >30	12018	HCPCS	450	RC		outpatient	718.5	610.73	Medicare A ID JF	Default	Other	280.22		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	156.16	696.94
LAC FACE/EAR SIMPLE >30	12018	HCPCS	450	RC		outpatient	718.5	610.73	Medicare B ID JF	Default	Fee Schedule	156.16		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		156.16	696.94
LAC FACE/EAR SIMPLE >30	12018	HCPCS	450	RC		outpatient	718.5	610.73	Regence Group Administrators	Default	Fee Schedule	696.94				156.16	696.94
LAC FACE/EAR SIMPLE >30	12018	HCPCS	450	RC		outpatient	718.5	610.73	SelectHealth	Default	Percent of Total Billed Charges	682.58				156.16	696.94
CLOSURE OF SPLIT WOUND	12020	HCPCS	450	RC		outpatient	760	646	Blue Cross of ID	Default	Percent of Total Billed Charges	737.2				274.86	737.2
CLOSURE OF SPLIT WOUND	12020	HCPCS	450	RC		outpatient	760	646	Medicaid Idaho	Default	Fee Schedule	349.6				274.86	737.2
CLOSURE OF SPLIT WOUND	12020	HCPCS	450	RC		outpatient	760	646	Medicare A ID JF	Default	Other	296.4		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	274.86	737.2
CLOSURE OF SPLIT WOUND	12020	HCPCS	450	RC		outpatient	760	646	Medicare B ID JF	Default	Fee Schedule	274.86		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		274.86	737.2
CLOSURE OF SPLIT WOUND	12020	HCPCS	450	RC		outpatient	760	646	Regence Group Administrators	Default	Fee Schedule	737.2				274.86	737.2
CLOSURE OF SPLIT WOUND	12020	HCPCS	450	RC		outpatient	760	646	SelectHealth	Default	Percent of Total Billed Charges	722				274.86	737.2
LAC MED S/A/T/E <2.05	12031	HCPCS	450	RC		outpatient	388.5	330.23	Blue Cross of ID	Default	Percent of Total Billed Charges	376.84				151.52	376.84
LAC MED S/A/T/E <2.05	12031	HCPCS	450	RC		outpatient	388.5	330.23	Medicaid Idaho	Default	Fee Schedule	178.71				151.52	376.84
LAC MED S/A/T/E <2.05	12031	HCPCS	450	RC		outpatient	388.5	330.23	Medicare A ID JF	Default	Other	151.52		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	151.52	376.84
LAC MED S/A/T/E <2.05	12031	HCPCS	450	RC		outpatient	388.5	330.23	Medicare B ID JF	Default	Fee Schedule	241.49		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		151.52	376.84
LAC MED S/A/T/E <2.05	12031	HCPCS	450	RC		outpatient	388.5	330.23	Regence Group Administrators	Default	Fee Schedule	376.84				151.52	376.84
LAC MED S/A/T/E <2.05	12031	HCPCS	450	RC		outpatient	388.5	330.23	SelectHealth	Default	Percent of Total Billed Charges	369.08				151.52	376.84
LAC MED S/A/T/E 2.6-7.5CM	12032	HCPCS	450	RC		outpatient	572.5	486.63	Blue Cross of ID	Default	Percent of Total Billed Charges	555.32				223.28	555.32
LAC MED S/A/T/E 2.6-7.5CM	12032	HCPCS	450	RC		outpatient	572.5	486.63	Medicaid Idaho	Default	Fee Schedule	263.35				223.28	555.32
LAC MED S/A/T/E 2.6-7.5CM	12032	HCPCS	450	RC		outpatient	572.5	486.63	Medicare A ID JF	Default	Other	223.28		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	223.28	555.32
LAC MED S/A/T/E 2.6-7.5CM	12032	HCPCS	450	RC		outpatient	572.5	486.63	Medicare B ID JF	Default	Fee Schedule	279.66		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		223.28	555.32
LAC MED S/A/T/E 2.6-7.5CM	12032	HCPCS	450	RC		outpatient	572.5	486.63	Regence Group Administrators	Default	Fee Schedule	555.32				223.28	555.32
LAC MED S/A/T/E 2.6-7.5CM	12032	HCPCS	450	RC		outpatient	572.5	486.63	SelectHealth	Default	Percent of Total Billed Charges	543.88				223.28	555.32
LAC MED S/A/T/E 7.6-12.5CM	12034	HCPCS	450	RC		outpatient	684.5	581.83	Blue Cross of ID	Default	Percent of Total Billed Charges	663.96				266.96	663.96
LAC MED S/A/T/E 7.6-12.5CM	12034	HCPCS	450	RC		outpatient	684.5	581.83	Medicaid Idaho	Default	Fee Schedule	314.87				266.96	663.96
LAC MED S/A/T/E 7.6-12.5CM	12034	HCPCS	450	RC		outpatient	684.5	581.83	Medicare A ID JF	Default	Other	266.96		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	266.96	663.96
LAC MED S/A/T/E 7.6-12.5CM	12034	HCPCS	450	RC		outpatient	684.5	581.83	Medicare B ID JF	Default	Fee Schedule	307.51		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		266.96	663.96
LAC MED S/A/T/E 7.6-12.5CM	12034	HCPCS	450	RC		outpatient	684.5	581.83	Regence Group Administrators	Default	Fee Schedule	663.96				266.96	663.96
LAC MED S/A/T/E 7.6-12.5CM	12034	HCPCS	450	RC		outpatient	684.5	581.83	SelectHealth	Default	Percent of Total Billed Charges	650.28				266.96	663.96
LAC MED S/A/T/E 12.6-20CM	12035	HCPCS	450	RC		outpatient	760	646	Blue Cross of ID	Default	Percent of Total Billed Charges	737.2				296.4	737.2
LAC MED S/A/T/E 12.6-20CM	12035	HCPCS	450	RC		outpatient	760	646	Medicaid Idaho	Default	Fee Schedule	349.6				296.4	737.2
LAC MED S/A/T/E 12.6-20CM	12035	HCPCS	450	RC		outpatient	760	646	Medicare A ID JF	Default	Other	296.4		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	296.4	737.2
LAC MED S/A/T/E 12.6-20CM	12035	HCPCS	450	RC		outpatient	760	646	Medicare B ID JF	Default	Fee Schedule	355.28		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		296.4	737.2
LAC MED S/A/T/E 12.6-20CM	12035	HCPCS	450	RC		outpatient	760	646	Regence Group Administrators	Default	Fee Schedule	737.2				296.4	737.2
LAC MED S/A/T/E 12.6-20CM	12035	HCPCS	450	RC		outpatient	760	646	SelectHealth	Default	Percent of Total Billed Charges	722				296.4	737.2
LAC MED S/A/T/E 20.1-30CM	12036	HCPCS	450	RC		outpatient	817.5	694.88	Blue Cross of ID	Default	Percent of Total Billed Charges	792.98				318.83	792.98
LAC MED S/A/T/E 20.1-30CM	12036	HCPCS	450	RC		outpatient	817.5	694.88	Medicaid Idaho	Default	Fee Schedule	376.05				318.83	792.98
LAC MED S/A/T/E 20.1-30CM	12036	HCPCS	450	RC		outpatient	817.5	694.88	Medicare A ID JF	Default	Other	318.83		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	318.83	792.98
LAC MED S/A/T/E 20.1-30CM	12036	HCPCS	450	RC		outpatient	817.5	694.88	Medicare B ID JF	Default	Fee Schedule	394.3		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		318.83	792.98
LAC MED S/A/T/E 20.1-30CM	12036	HCPCS	450	RC		outpatient	817.5	694.88	Regence Group Administrators	Default	Fee Schedule	792.98				318.83	792.98
LAC MED S/A/T/E 20.1-30CM	12036	HCPCS	450	RC		outpatient	817.5	694.88	SelectHealth	Default	Percent of Total Billed Charges	776.62				318.83	792.98
LAC MED S/A/T/E >30CM	12037	HCPCS	450	RC		outpatient	1784	1516.4	Blue Cross of ID	Default	Percent of Total Billed Charges	1730.48				442.64	1730.48
LAC MED S/A/T/E >30CM	12037	HCPCS	450	RC		outpatient	1784	1516.4	Medicaid Idaho	Default	Fee Schedule	820.64				442.64	1730.48
LAC MED S/A/T/E >30CM	12037	HCPCS	450	RC		outpatient	1784	1516.4	Medicare A ID JF	Default	Other	695.76		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	442.64	1730.48
LAC MED S/A/T/E >30CM	12037	HCPCS	450	RC		outpatient	1784	1516.4	Medicare B ID JF	Default	Fee Schedule	442.64		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		442.64	1730.48
LAC MED S/A/T/E >30CM	12037	HCPCS	450	RC		outpatient	1784	1516.4	Regence Group Administrators	Default	Fee Schedule	1730.48				442.64	1730.48
LAC MED S/A/T/E >30CM	12037	HCPCS	450	RC		outpatient	1784	1516.4	SelectHealth	Default	Percent of Total Billed Charges	1694.8				442.64	1730.48
LAC MED N/H/F/G <2.5CM	12041	HCPCS	450	RC		outpatient	525	446.25	Blue Cross of ID	Default	Percent of Total Billed Charges	509.25				204.75	509.25
LAC MED N/H/F/G <2.5CM	12041	HCPCS	450	RC		outpatient	525	446.25	Medicaid Idaho	Default	Fee Schedule	241.5				204.75	509.25
LAC MED N/H/F/G <2.5CM	12041	HCPCS	450	RC		outpatient	525	446.25	Medicare A ID JF	Default	Other	204.75		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	204.75	509.25
LAC MED N/H/F/G <2.5CM	12041	HCPCS	450	RC		outpatient	525	446.25	Medicare B ID JF	Default	Fee Schedule	242.25		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		204.75	509.25
LAC MED N/H/F/G <2.5CM	12041	HCPCS	450	RC		outpatient	525	446.25	Regence Group Administrators	Default	Fee Schedule	509.25				204.75	509.25
LAC MED N/H/F/G <2.5CM	12041	HCPCS	450	RC		outpatient	525	446.25	SelectHealth	Default	Percent of Total Billed Charges	498.75				204.75	509.25
LAC MED N/H/F/G 2.6-7.5CM	12042	HCPCS	450	RC		outpatient	555.5	472.18	Blue Cross of ID	Default	Percent of Total Billed Charges	538.84				216.65	538.84
LAC MED N/H/F/G 2.6-7.5CM	12042	HCPCS	450	RC		outpatient	555.5	472.18	Medicaid Idaho	Default	Fee Schedule	255.53				216.65	538.84
LAC MED N/H/F/G 2.6-7.5CM	12042	HCPCS	450	RC		outpatient	555.5	472.18	Medicare A ID JF	Default	Other	216.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	216.65	538.84
LAC MED N/H/F/G 2.6-7.5CM	12042	HCPCS	450	RC		outpatient	555.5	472.18	Medicare B ID JF	Default	Fee Schedule	285.63		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		216.65	538.84
LAC MED N/H/F/G 2.6-7.5CM	12042	HCPCS	450	RC		outpatient	555.5	472.18	Regence Group Administrators	Default	Fee Schedule	538.84				216.65	538.84
LAC MED N/H/F/G 2.6-7.5CM	12042	HCPCS	450	RC		outpatient	555.5	472.18	SelectHealth	Default	Percent of Total Billed Charges	527.72				216.65	538.84
LAC MED N/H/F/G 7.6-12.5CM	12044	HCPCS	450	RC		outpatient	598.5	508.73	Blue Cross of ID	Default	Percent of Total Billed Charges	580.54				233.42	580.54
LAC MED N/H/F/G 7.6-12.5CM	12044	HCPCS	450	RC		outpatient	598.5	508.73	Medicaid Idaho	Default	Fee Schedule	275.31				233.42	580.54
LAC MED N/H/F/G 7.6-12.5CM	12044	HCPCS	450	RC		outpatient	598.5	508.73	Medicare A ID JF	Default	Other	233.42		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	233.42	580.54
LAC MED N/H/F/G 7.6-12.5CM	12044	HCPCS	450	RC		outpatient	598.5	508.73	Medicare B ID JF	Default	Fee Schedule	350.96		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		233.42	580.54
LAC MED N/H/F/G 7.6-12.5CM	12044	HCPCS	450	RC		outpatient	598.5	508.73	Regence Group Administrators	Default	Fee Schedule	580.54				233.42	580.54
LAC MED N/H/F/G 7.6-12.5CM	12044	HCPCS	450	RC		outpatient	598.5	508.73	SelectHealth	Default	Percent of Total Billed Charges	568.58				233.42	580.54
LAC MED N/H/F/G 12.6-20CM	12045	HCPCS	450	RC		outpatient	665.5	565.68	Blue Cross of ID	Default	Percent of Total Billed Charges	645.54				259.55	645.54
LAC MED N/H/F/G 12.6-20CM	12045	HCPCS	450	RC		outpatient	665.5	565.68	Medicaid Idaho	Default	Fee Schedule	306.13				259.55	645.54
LAC MED N/H/F/G 12.6-20CM	12045	HCPCS	450	RC		outpatient	665.5	565.68	Medicare A ID JF	Default	Other	259.55		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	259.55	645.54
LAC MED N/H/F/G 12.6-20CM	12045	HCPCS	450	RC		outpatient	665.5	565.68	Medicare B ID JF	Default	Fee Schedule	377.22		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		259.55	645.54
LAC MED N/H/F/G 12.6-20CM	12045	HCPCS	450	RC		outpatient	665.5	565.68	Regence Group Administrators	Default	Fee Schedule	645.54				259.55	645.54
LAC MED N/H/F/G 12.6-20CM	12045	HCPCS	450	RC		outpatient	665.5	565.68	SelectHealth	Default	Percent of Total Billed Charges	632.22				259.55	645.54
LAC MED N/H/F/G 20.1-30CM	12046	HCPCS	450	RC		outpatient	716	608.6	Blue Cross of ID	Default	Percent of Total Billed Charges	694.52				279.24	694.52
LAC MED N/H/F/G 20.1-30CM	12046	HCPCS	450	RC		outpatient	716	608.6	Medicaid Idaho	Default	Fee Schedule	329.36				279.24	694.52
LAC MED N/H/F/G 20.1-30CM	12046	HCPCS	450	RC		outpatient	716	608.6	Medicare A ID JF	Default	Other	279.24		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	279.24	694.52
LAC MED N/H/F/G 20.1-30CM	12046	HCPCS	450	RC		outpatient	716	608.6	Medicare B ID JF	Default	Fee Schedule	451.99		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		279.24	694.52
LAC MED N/H/F/G 20.1-30CM	12046	HCPCS	450	RC		outpatient	716	608.6	Regence Group Administrators	Default	Fee Schedule	694.52				279.24	694.52
LAC MED N/H/F/G 20.1-30CM	12046	HCPCS	450	RC		outpatient	716	608.6	SelectHealth	Default	Percent of Total Billed Charges	680.2				279.24	694.52
LAC MED N/H/F/G >30	12047	HCPCS	450	RC		outpatient	1784	1516.4	Blue Cross of ID	Default	Percent of Total Billed Charges	1730.48				494.98	1730.48
LAC MED N/H/F/G >30	12047	HCPCS	450	RC		outpatient	1784	1516.4	Medicaid Idaho	Default	Fee Schedule	820.64				494.98	1730.48
LAC MED N/H/F/G >30	12047	HCPCS	450	RC		outpatient	1784	1516.4	Medicare A ID JF	Default	Other	695.76		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	494.98	1730.48
LAC MED N/H/F/G >30	12047	HCPCS	450	RC		outpatient	1784	1516.4	Medicare B ID JF	Default	Fee Schedule	494.98		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		494.98	1730.48
LAC MED N/H/F/G >30	12047	HCPCS	450	RC		outpatient	1784	1516.4	Regence Group Administrators	Default	Fee Schedule	1730.48				494.98	1730.48
LAC MED N/H/F/G >30	12047	HCPCS	450	RC		outpatient	1784	1516.4	SelectHealth	Default	Percent of Total Billed Charges	1694.8				494.98	1730.48
LAC MED FACE/EAR <2.5CM	12051	HCPCS	450	RC		outpatient	418.5	355.73	Blue Cross of ID	Default	Percent of Total Billed Charges	405.94				163.22	405.94
LAC MED FACE/EAR <2.5CM	12051	HCPCS	450	RC		outpatient	418.5	355.73	Medicaid Idaho	Default	Fee Schedule	192.51				163.22	405.94
LAC MED FACE/EAR <2.5CM	12051	HCPCS	450	RC		outpatient	418.5	355.73	Medicare A ID JF	Default	Other	163.22		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	163.22	405.94
LAC MED FACE/EAR <2.5CM	12051	HCPCS	450	RC		outpatient	418.5	355.73	Medicare B ID JF	Default	Fee Schedule	260.34		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		163.22	405.94
LAC MED FACE/EAR <2.5CM	12051	HCPCS	450	RC		outpatient	418.5	355.73	Regence Group Administrators	Default	Fee Schedule	405.94				163.22	405.94
LAC MED FACE/EAR <2.5CM	12051	HCPCS	450	RC		outpatient	418.5	355.73	SelectHealth	Default	Percent of Total Billed Charges	397.58				163.22	405.94
LAC MED FACE/EAR 2.6-5CM	12052	HCPCS	450	RC		outpatient	574	487.9	Blue Cross of ID	Default	Percent of Total Billed Charges	556.78				223.86	556.78
LAC MED FACE/EAR 2.6-5CM	12052	HCPCS	450	RC		outpatient	574	487.9	Medicaid Idaho	Default	Fee Schedule	264.04				223.86	556.78
LAC MED FACE/EAR 2.6-5CM	12052	HCPCS	450	RC		outpatient	574	487.9	Medicare A ID JF	Default	Other	223.86		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	223.86	556.78
LAC MED FACE/EAR 2.6-5CM	12052	HCPCS	450	RC		outpatient	574	487.9	Medicare B ID JF	Default	Fee Schedule	290.42		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		223.86	556.78
LAC MED FACE/EAR 2.6-5CM	12052	HCPCS	450	RC		outpatient	574	487.9	Regence Group Administrators	Default	Fee Schedule	556.78				223.86	556.78
LAC MED FACE/EAR 2.6-5CM	12052	HCPCS	450	RC		outpatient	574	487.9	SelectHealth	Default	Percent of Total Billed Charges	545.3				223.86	556.78
LAC MED FACE/EAR 5.1-7.5CM	12053	HCPCS	450	RC		outpatient	597.5	507.88	Blue Cross of ID	Default	Percent of Total Billed Charges	579.58				233.03	579.58
LAC MED FACE/EAR 5.1-7.5CM	12053	HCPCS	450	RC		outpatient	597.5	507.88	Medicaid Idaho	Default	Fee Schedule	274.85				233.03	579.58
LAC MED FACE/EAR 5.1-7.5CM	12053	HCPCS	450	RC		outpatient	597.5	507.88	Medicare A ID JF	Default	Other	233.03		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	233.03	579.58
LAC MED FACE/EAR 5.1-7.5CM	12053	HCPCS	450	RC		outpatient	597.5	507.88	Medicare B ID JF	Default	Fee Schedule	334.12		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		233.03	579.58
LAC MED FACE/EAR 5.1-7.5CM	12053	HCPCS	450	RC		outpatient	597.5	507.88	Regence Group Administrators	Default	Fee Schedule	579.58				233.03	579.58
LAC MED FACE/EAR 5.1-7.5CM	12053	HCPCS	450	RC		outpatient	597.5	507.88	SelectHealth	Default	Percent of Total Billed Charges	567.62				233.03	579.58
LAC MED FACE/EAR 7.6-12.5CM	12054	HCPCS	450	RC		outpatient	684.5	581.83	Blue Cross of ID	Default	Percent of Total Billed Charges	663.96				266.96	663.96
LAC MED FACE/EAR 7.6-12.5CM	12054	HCPCS	450	RC		outpatient	684.5	581.83	Medicaid Idaho	Default	Fee Schedule	314.87				266.96	663.96
LAC MED FACE/EAR 7.6-12.5CM	12054	HCPCS	450	RC		outpatient	684.5	581.83	Medicare A ID JF	Default	Other	266.96		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	266.96	663.96
LAC MED FACE/EAR 7.6-12.5CM	12054	HCPCS	450	RC		outpatient	684.5	581.83	Medicare B ID JF	Default	Fee Schedule	350.87		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		266.96	663.96
LAC MED FACE/EAR 7.6-12.5CM	12054	HCPCS	450	RC		outpatient	684.5	581.83	Regence Group Administrators	Default	Fee Schedule	663.96				266.96	663.96
LAC MED FACE/EAR 7.6-12.5CM	12054	HCPCS	450	RC		outpatient	684.5	581.83	SelectHealth	Default	Percent of Total Billed Charges	650.28				266.96	663.96
LAC MED FACE/EAR 12.6-20CM	12055	HCPCS	450	RC		outpatient	760	646	Blue Cross of ID	Default	Percent of Total Billed Charges	737.2				296.4	737.2
LAC MED FACE/EAR 12.6-20CM	12055	HCPCS	450	RC		outpatient	760	646	Medicaid Idaho	Default	Fee Schedule	349.6				296.4	737.2
LAC MED FACE/EAR 12.6-20CM	12055	HCPCS	450	RC		outpatient	760	646	Medicare A ID JF	Default	Other	296.4		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	296.4	737.2
LAC MED FACE/EAR 12.6-20CM	12055	HCPCS	450	RC		outpatient	760	646	Medicare B ID JF	Default	Fee Schedule	459.03		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		296.4	737.2
LAC MED FACE/EAR 12.6-20CM	12055	HCPCS	450	RC		outpatient	760	646	Regence Group Administrators	Default	Fee Schedule	737.2				296.4	737.2
LAC MED FACE/EAR 12.6-20CM	12055	HCPCS	450	RC		outpatient	760	646	SelectHealth	Default	Percent of Total Billed Charges	722				296.4	737.2
LAC MED FACE/EAR 20.1-30CM	12056	HCPCS	450	RC		outpatient	791	672.35	Blue Cross of ID	Default	Percent of Total Billed Charges	767.27				308.49	767.27
LAC MED FACE/EAR 20.1-30CM	12056	HCPCS	450	RC		outpatient	791	672.35	Medicaid Idaho	Default	Fee Schedule	363.86				308.49	767.27
LAC MED FACE/EAR 20.1-30CM	12056	HCPCS	450	RC		outpatient	791	672.35	Medicare A ID JF	Default	Other	308.49		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	308.49	767.27
LAC MED FACE/EAR 20.1-30CM	12056	HCPCS	450	RC		outpatient	791	672.35	Medicare B ID JF	Default	Fee Schedule	528.17		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		308.49	767.27
LAC MED FACE/EAR 20.1-30CM	12056	HCPCS	450	RC		outpatient	791	672.35	Regence Group Administrators	Default	Fee Schedule	767.27				308.49	767.27
LAC MED FACE/EAR 20.1-30CM	12056	HCPCS	450	RC		outpatient	791	672.35	SelectHealth	Default	Percent of Total Billed Charges	751.45				308.49	767.27
LAC MED FACE/EAR >30CM	12057	HCPCS	450	RC		outpatient	790.5	671.93	Blue Cross of ID	Default	Percent of Total Billed Charges	766.78				308.3	766.78
LAC MED FACE/EAR >30CM	12057	HCPCS	450	RC		outpatient	790.5	671.93	Medicaid Idaho	Default	Fee Schedule	363.63				308.3	766.78
LAC MED FACE/EAR >30CM	12057	HCPCS	450	RC		outpatient	790.5	671.93	Medicare A ID JF	Default	Other	308.3		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	308.3	766.78
LAC MED FACE/EAR >30CM	12057	HCPCS	450	RC		outpatient	790.5	671.93	Medicare B ID JF	Default	Fee Schedule	552.71		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		308.3	766.78
LAC MED FACE/EAR >30CM	12057	HCPCS	450	RC		outpatient	790.5	671.93	Regence Group Administrators	Default	Fee Schedule	766.78				308.3	766.78
LAC MED FACE/EAR >30CM	12057	HCPCS	450	RC		outpatient	790.5	671.93	SelectHealth	Default	Percent of Total Billed Charges	750.98				308.3	766.78
REPAIR COMPLEX TRUNK 1.1-2.5CM	13100	HCPCS	450	RC		outpatient	562	477.7	Blue Cross of ID	Default	Percent of Total Billed Charges	545.14				219.18	545.14
REPAIR COMPLEX TRUNK 1.1-2.5CM	13100	HCPCS	450	RC		outpatient	562	477.7	Medicaid Idaho	Default	Fee Schedule	258.52				219.18	545.14
REPAIR COMPLEX TRUNK 1.1-2.5CM	13100	HCPCS	450	RC		outpatient	562	477.7	Medicare A ID JF	Default	Other	219.18		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	219.18	545.14
REPAIR COMPLEX TRUNK 1.1-2.5CM	13100	HCPCS	450	RC		outpatient	562	477.7	Medicare B ID JF	Default	Fee Schedule	312.74		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		219.18	545.14
REPAIR COMPLEX TRUNK 1.1-2.5CM	13100	HCPCS	450	RC		outpatient	562	477.7	Regence Group Administrators	Default	Fee Schedule	545.14				219.18	545.14
REPAIR COMPLEX TRUNK 1.1-2.5CM	13100	HCPCS	450	RC		outpatient	562	477.7	SelectHealth	Default	Percent of Total Billed Charges	533.9				219.18	545.14
REPAIR COMPLEX TRUNK 2.6-7.5CM	13101	HCPCS	450	RC		outpatient	858	729.3	Blue Cross of ID	Default	Percent of Total Billed Charges	832.26				334.62	832.26
REPAIR COMPLEX TRUNK 2.6-7.5CM	13101	HCPCS	450	RC		outpatient	858	729.3	Medicaid Idaho	Default	Fee Schedule	394.68				334.62	832.26
REPAIR COMPLEX TRUNK 2.6-7.5CM	13101	HCPCS	450	RC		outpatient	858	729.3	Medicare A ID JF	Default	Other	334.62		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	334.62	832.26
REPAIR COMPLEX TRUNK 2.6-7.5CM	13101	HCPCS	450	RC		outpatient	858	729.3	Medicare B ID JF	Default	Fee Schedule	364.45		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		334.62	832.26
REPAIR COMPLEX TRUNK 2.6-7.5CM	13101	HCPCS	450	RC		outpatient	858	729.3	Regence Group Administrators	Default	Fee Schedule	832.26				334.62	832.26
REPAIR COMPLEX TRUNK 2.6-7.5CM	13101	HCPCS	450	RC		outpatient	858	729.3	SelectHealth	Default	Percent of Total Billed Charges	815.1				334.62	832.26
REPAIR COMPLEX EA ADDITIONAL 5 CM	13102	HCPCS	450	RC		outpatient	342.5	291.13	Blue Cross of ID	Default	Percent of Total Billed Charges	332.22				106.31	332.22
REPAIR COMPLEX EA ADDITIONAL 5 CM	13102	HCPCS	450	RC		outpatient	342.5	291.13	Medicaid Idaho	Default	Fee Schedule	157.55				106.31	332.22
REPAIR COMPLEX EA ADDITIONAL 5 CM	13102	HCPCS	450	RC		outpatient	342.5	291.13	Medicare A ID JF	Default	Other	133.58		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	106.31	332.22
REPAIR COMPLEX EA ADDITIONAL 5 CM	13102	HCPCS	450	RC		outpatient	342.5	291.13	Medicare B ID JF	Default	Fee Schedule	106.31		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		106.31	332.22
REPAIR COMPLEX EA ADDITIONAL 5 CM	13102	HCPCS	450	RC		outpatient	342.5	291.13	Regence Group Administrators	Default	Fee Schedule	332.22				106.31	332.22
REPAIR COMPLEX EA ADDITIONAL 5 CM	13102	HCPCS	450	RC		outpatient	342.5	291.13	SelectHealth	Default	Percent of Total Billed Charges	325.38				106.31	332.22
REPAIR COMPLEX SCALP 1.1-2.5CM	13120	HCPCS	450	RC		outpatient	570.5	484.93	Blue Cross of ID	Default	Percent of Total Billed Charges	553.38				222.5	553.38
REPAIR COMPLEX SCALP 1.1-2.5CM	13120	HCPCS	450	RC		outpatient	570.5	484.93	Medicaid Idaho	Default	Fee Schedule	262.43				222.5	553.38
REPAIR COMPLEX SCALP 1.1-2.5CM	13120	HCPCS	450	RC		outpatient	570.5	484.93	Medicare A ID JF	Default	Other	222.5		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	222.5	553.38
REPAIR COMPLEX SCALP 1.1-2.5CM	13120	HCPCS	450	RC		outpatient	570.5	484.93	Medicare B ID JF	Default	Fee Schedule	326.14		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		222.5	553.38
REPAIR COMPLEX SCALP 1.1-2.5CM	13120	HCPCS	450	RC		outpatient	570.5	484.93	Regence Group Administrators	Default	Fee Schedule	553.38				222.5	553.38
REPAIR COMPLEX SCALP 1.1-2.5CM	13120	HCPCS	450	RC		outpatient	570.5	484.93	SelectHealth	Default	Percent of Total Billed Charges	541.98				222.5	553.38
REPAIR COMPLEX SCALP 2.6-7.5CM	13121	HCPCS	450	RC		outpatient	738.5	627.73	Blue Cross of ID	Default	Percent of Total Billed Charges	716.34				288.02	716.34
REPAIR COMPLEX SCALP 2.6-7.5CM	13121	HCPCS	450	RC		outpatient	738.5	627.73	Medicaid Idaho	Default	Fee Schedule	339.71				288.02	716.34
REPAIR COMPLEX SCALP 2.6-7.5CM	13121	HCPCS	450	RC		outpatient	738.5	627.73	Medicare A ID JF	Default	Other	288.02		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	288.02	716.34
REPAIR COMPLEX SCALP 2.6-7.5CM	13121	HCPCS	450	RC		outpatient	738.5	627.73	Medicare B ID JF	Default	Fee Schedule	390.93		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		288.02	716.34
REPAIR COMPLEX SCALP 2.6-7.5CM	13121	HCPCS	450	RC		outpatient	738.5	627.73	Regence Group Administrators	Default	Fee Schedule	716.34				288.02	716.34
REPAIR COMPLEX SCALP 2.6-7.5CM	13121	HCPCS	450	RC		outpatient	738.5	627.73	SelectHealth	Default	Percent of Total Billed Charges	701.58				288.02	716.34
REPAIR COMPLEX SCALP EA ADDITIONAL 5 CM	13122	HCPCS	450	RC		outpatient	307.5	261.38	Blue Cross of ID	Default	Percent of Total Billed Charges	298.28				115.99	298.28
REPAIR COMPLEX SCALP EA ADDITIONAL 5 CM	13122	HCPCS	450	RC		outpatient	307.5	261.38	Medicaid Idaho	Default	Fee Schedule	141.45				115.99	298.28
REPAIR COMPLEX SCALP EA ADDITIONAL 5 CM	13122	HCPCS	450	RC		outpatient	307.5	261.38	Medicare A ID JF	Default	Other	119.93		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	115.99	298.28
REPAIR COMPLEX SCALP EA ADDITIONAL 5 CM	13122	HCPCS	450	RC		outpatient	307.5	261.38	Medicare B ID JF	Default	Fee Schedule	115.99		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		115.99	298.28
REPAIR COMPLEX SCALP EA ADDITIONAL 5 CM	13122	HCPCS	450	RC		outpatient	307.5	261.38	Regence Group Administrators	Default	Fee Schedule	298.28				115.99	298.28
REPAIR COMPLEX SCALP EA ADDITIONAL 5 CM	13122	HCPCS	450	RC		outpatient	307.5	261.38	SelectHealth	Default	Percent of Total Billed Charges	292.12				115.99	298.28
REPAIR COMPLEX FOREHEAD 1.1-2.5CM	13131	HCPCS	450	RC		outpatient	495	420.75	Blue Cross of ID	Default	Percent of Total Billed Charges	480.15				193.05	480.15
REPAIR COMPLEX FOREHEAD 1.1-2.5CM	13131	HCPCS	450	RC		outpatient	495	420.75	Medicaid Idaho	Default	Fee Schedule	227.7				193.05	480.15
REPAIR COMPLEX FOREHEAD 1.1-2.5CM	13131	HCPCS	450	RC		outpatient	495	420.75	Medicare A ID JF	Default	Other	193.05		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	193.05	480.15
REPAIR COMPLEX FOREHEAD 1.1-2.5CM	13131	HCPCS	450	RC		outpatient	495	420.75	Medicare B ID JF	Default	Fee Schedule	356.7		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		193.05	480.15
REPAIR COMPLEX FOREHEAD 1.1-2.5CM	13131	HCPCS	450	RC		outpatient	495	420.75	Regence Group Administrators	Default	Fee Schedule	480.15				193.05	480.15
REPAIR COMPLEX FOREHEAD 1.1-2.5CM	13131	HCPCS	450	RC		outpatient	495	420.75	SelectHealth	Default	Percent of Total Billed Charges	470.25				193.05	480.15
LAC COMPLEX N/H/F/G 2.6-7.5CM	13132	HCPCS	450	RC		outpatient	684.5	581.83	Blue Cross of ID	Default	Percent of Total Billed Charges	663.96				266.96	663.96
LAC COMPLEX N/H/F/G 2.6-7.5CM	13132	HCPCS	450	RC		outpatient	684.5	581.83	Medicaid Idaho	Default	Fee Schedule	314.87				266.96	663.96
LAC COMPLEX N/H/F/G 2.6-7.5CM	13132	HCPCS	450	RC		outpatient	684.5	581.83	Medicare A ID JF	Default	Other	266.96		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	266.96	663.96
LAC COMPLEX N/H/F/G 2.6-7.5CM	13132	HCPCS	450	RC		outpatient	684.5	581.83	Medicare B ID JF	Default	Fee Schedule	433.23		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		266.96	663.96
LAC COMPLEX N/H/F/G 2.6-7.5CM	13132	HCPCS	450	RC		outpatient	684.5	581.83	Regence Group Administrators	Default	Fee Schedule	663.96				266.96	663.96
LAC COMPLEX N/H/F/G 2.6-7.5CM	13132	HCPCS	450	RC		outpatient	684.5	581.83	SelectHealth	Default	Percent of Total Billed Charges	650.28				266.96	663.96
LAC COMPLEX N/H/F/G EA ADDITIONAL 5CM	13133	HCPCS	450	RC		outpatient	373.5	317.48	Blue Cross of ID	Default	Percent of Total Billed Charges	362.3				145.67	362.3
LAC COMPLEX N/H/F/G EA ADDITIONAL 5CM	13133	HCPCS	450	RC		outpatient	373.5	317.48	Medicaid Idaho	Default	Fee Schedule	171.81				145.67	362.3
LAC COMPLEX N/H/F/G EA ADDITIONAL 5CM	13133	HCPCS	450	RC		outpatient	373.5	317.48	Medicare A ID JF	Default	Other	145.67		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	145.67	362.3
LAC COMPLEX N/H/F/G EA ADDITIONAL 5CM	13133	HCPCS	450	RC		outpatient	373.5	317.48	Medicare B ID JF	Default	Fee Schedule	154.73		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		145.67	362.3
LAC COMPLEX N/H/F/G EA ADDITIONAL 5CM	13133	HCPCS	450	RC		outpatient	373.5	317.48	Regence Group Administrators	Default	Fee Schedule	362.3				145.67	362.3
LAC COMPLEX N/H/F/G EA ADDITIONAL 5CM	13133	HCPCS	450	RC		outpatient	373.5	317.48	SelectHealth	Default	Percent of Total Billed Charges	354.82				145.67	362.3
LAC COMPLEX EYELID/LIP/NOSE/EAR 1.1-2.5C	13151	HCPCS	450	RC		outpatient	753.5	640.48	Blue Cross of ID	Default	Percent of Total Billed Charges	730.9				293.87	730.9
LAC COMPLEX EYELID/LIP/NOSE/EAR 1.1-2.5C	13151	HCPCS	450	RC		outpatient	753.5	640.48	Medicaid Idaho	Default	Fee Schedule	346.61				293.87	730.9
LAC COMPLEX EYELID/LIP/NOSE/EAR 1.1-2.5C	13151	HCPCS	450	RC		outpatient	753.5	640.48	Medicare A ID JF	Default	Other	293.87		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	293.87	730.9
LAC COMPLEX EYELID/LIP/NOSE/EAR 1.1-2.5C	13151	HCPCS	450	RC		outpatient	753.5	640.48	Medicare B ID JF	Default	Fee Schedule	388.81		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		293.87	730.9
LAC COMPLEX EYELID/LIP/NOSE/EAR 1.1-2.5C	13151	HCPCS	450	RC		outpatient	753.5	640.48	Regence Group Administrators	Default	Fee Schedule	730.9				293.87	730.9
LAC COMPLEX EYELID/LIP/NOSE/EAR 1.1-2.5C	13151	HCPCS	450	RC		outpatient	753.5	640.48	SelectHealth	Default	Percent of Total Billed Charges	715.82				293.87	730.9
LAC COMPLEX EYELID/LIP/NOSE/EAR 2.6-7.5C	13152	HCPCS	450	RC		outpatient	908.5	772.23	Blue Cross of ID	Default	Percent of Total Billed Charges	881.24				354.32	881.24
LAC COMPLEX EYELID/LIP/NOSE/EAR 2.6-7.5C	13152	HCPCS	450	RC		outpatient	908.5	772.23	Medicaid Idaho	Default	Fee Schedule	417.91				354.32	881.24
LAC COMPLEX EYELID/LIP/NOSE/EAR 2.6-7.5C	13152	HCPCS	450	RC		outpatient	908.5	772.23	Medicare A ID JF	Default	Other	354.32		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	354.32	881.24
LAC COMPLEX EYELID/LIP/NOSE/EAR 2.6-7.5C	13152	HCPCS	450	RC		outpatient	908.5	772.23	Medicare B ID JF	Default	Fee Schedule	456.89		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		354.32	881.24
LAC COMPLEX EYELID/LIP/NOSE/EAR 2.6-7.5C	13152	HCPCS	450	RC		outpatient	908.5	772.23	Regence Group Administrators	Default	Fee Schedule	881.24				354.32	881.24
LAC COMPLEX EYELID/LIP/NOSE/EAR 2.6-7.5C	13152	HCPCS	450	RC		outpatient	908.5	772.23	SelectHealth	Default	Percent of Total Billed Charges	863.08				354.32	881.24
BURN TX 1ST DEGREE	16000	HCPCS	450	RC		outpatient	355.5	302.18	Blue Cross of ID	Default	Percent of Total Billed Charges	344.84				73.18	344.84
BURN TX 1ST DEGREE	16000	HCPCS	450	RC		outpatient	355.5	302.18	Medicaid Idaho	Default	Fee Schedule	163.53				73.18	344.84
BURN TX 1ST DEGREE	16000	HCPCS	450	RC		outpatient	355.5	302.18	Medicare A ID JF	Default	Other	138.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	73.18	344.84
BURN TX 1ST DEGREE	16000	HCPCS	450	RC		outpatient	355.5	302.18	Medicare B ID JF	Default	Fee Schedule	73.18		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		73.18	344.84
BURN TX 1ST DEGREE	16000	HCPCS	450	RC		outpatient	355.5	302.18	Regence Group Administrators	Default	Fee Schedule	344.84				73.18	344.84
BURN TX 1ST DEGREE	16000	HCPCS	450	RC		outpatient	355.5	302.18	SelectHealth	Default	Percent of Total Billed Charges	337.72				73.18	344.84
BURN DRESS/DEBRID P-THICK SMALL	16020	HCPCS	450	RC		outpatient	194	164.9	Blue Cross of ID	Default	Percent of Total Billed Charges	188.18				75.66	188.18
BURN DRESS/DEBRID P-THICK SMALL	16020	HCPCS	450	RC		outpatient	194	164.9	Medicaid Idaho	Default	Fee Schedule	89.24				75.66	188.18
BURN DRESS/DEBRID P-THICK SMALL	16020	HCPCS	450	RC		outpatient	194	164.9	Medicare A ID JF	Default	Other	75.66		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	75.66	188.18
BURN DRESS/DEBRID P-THICK SMALL	16020	HCPCS	450	RC		outpatient	194	164.9	Medicare B ID JF	Default	Fee Schedule	78.67		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		75.66	188.18
BURN DRESS/DEBRID P-THICK SMALL	16020	HCPCS	450	RC		outpatient	194	164.9	Regence Group Administrators	Default	Fee Schedule	188.18				75.66	188.18
BURN DRESS/DEBRID P-THICK SMALL	16020	HCPCS	450	RC		outpatient	194	164.9	SelectHealth	Default	Percent of Total Billed Charges	184.3				75.66	188.18
BURN DRESS/DEBRIDMENT MEDIUM	16025	HCPCS	450	RC		outpatient	307	260.95	Blue Cross of ID	Default	Percent of Total Billed Charges	297.79				119.73	297.79
BURN DRESS/DEBRIDMENT MEDIUM	16025	HCPCS	450	RC		outpatient	307	260.95	Medicaid Idaho	Default	Fee Schedule	141.22				119.73	297.79
BURN DRESS/DEBRIDMENT MEDIUM	16025	HCPCS	450	RC		outpatient	307	260.95	Medicare A ID JF	Default	Other	119.73		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	119.73	297.79
BURN DRESS/DEBRIDMENT MEDIUM	16025	HCPCS	450	RC		outpatient	307	260.95	Medicare B ID JF	Default	Fee Schedule	144.28		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		119.73	297.79
BURN DRESS/DEBRIDMENT MEDIUM	16025	HCPCS	450	RC		outpatient	307	260.95	Regence Group Administrators	Default	Fee Schedule	297.79				119.73	297.79
BURN DRESS/DEBRIDMENT MEDIUM	16025	HCPCS	450	RC		outpatient	307	260.95	SelectHealth	Default	Percent of Total Billed Charges	291.65				119.73	297.79
BURN DRESS/DEBRIDMENT LARGE>10%	16030	HCPCS	450	RC		outpatient	403	342.55	Blue Cross of ID	Default	Percent of Total Billed Charges	390.91				157.17	390.91
BURN DRESS/DEBRIDMENT LARGE>10%	16030	HCPCS	450	RC		outpatient	403	342.55	Medicaid Idaho	Default	Fee Schedule	185.38				157.17	390.91
BURN DRESS/DEBRIDMENT LARGE>10%	16030	HCPCS	450	RC		outpatient	403	342.55	Medicare A ID JF	Default	Other	157.17		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	157.17	390.91
BURN DRESS/DEBRIDMENT LARGE>10%	16030	HCPCS	450	RC		outpatient	403	342.55	Medicare B ID JF	Default	Fee Schedule	179.66		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		157.17	390.91
BURN DRESS/DEBRIDMENT LARGE>10%	16030	HCPCS	450	RC		outpatient	403	342.55	Regence Group Administrators	Default	Fee Schedule	390.91				157.17	390.91
BURN DRESS/DEBRIDMENT LARGE>10%	16030	HCPCS	450	RC		outpatient	403	342.55	SelectHealth	Default	Percent of Total Billed Charges	382.85				157.17	390.91
WOUND EXPLORATATION EXTREMITY	20103	HCPCS	450	RC		outpatient	668	567.8	Blue Cross of ID	Default	Percent of Total Billed Charges	647.96				260.52	647.96
WOUND EXPLORATATION EXTREMITY	20103	HCPCS	450	RC		outpatient	668	567.8	Medicaid Idaho	Default	Fee Schedule	307.28				260.52	647.96
WOUND EXPLORATATION EXTREMITY	20103	HCPCS	450	RC		outpatient	668	567.8	Medicare A ID JF	Default	Other	260.52		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	260.52	647.96
WOUND EXPLORATATION EXTREMITY	20103	HCPCS	450	RC		outpatient	668	567.8	Medicare B ID JF	Default	Fee Schedule	513.64		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		260.52	647.96
WOUND EXPLORATATION EXTREMITY	20103	HCPCS	450	RC		outpatient	668	567.8	Regence Group Administrators	Default	Fee Schedule	647.96				260.52	647.96
WOUND EXPLORATATION EXTREMITY	20103	HCPCS	450	RC		outpatient	668	567.8	SelectHealth	Default	Percent of Total Billed Charges	634.6				260.52	647.96
INJ TRIGGER POINTS 1 -2 MUSCLES	20552	HCPCS	450	RC		outpatient	510	433.5	Blue Cross of ID	Default	Percent of Total Billed Charges	494.7				48.59	494.7
INJ TRIGGER POINTS 1 -2 MUSCLES	20552	HCPCS	450	RC		outpatient	510	433.5	Medicaid Idaho	Default	Fee Schedule	234.6				48.59	494.7
INJ TRIGGER POINTS 1 -2 MUSCLES	20552	HCPCS	450	RC		outpatient	510	433.5	Medicare A ID JF	Default	Other	198.9		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	48.59	494.7
INJ TRIGGER POINTS 1 -2 MUSCLES	20552	HCPCS	450	RC		outpatient	510	433.5	Medicare B ID JF	Default	Fee Schedule	48.59		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		48.59	494.7
INJ TRIGGER POINTS 1 -2 MUSCLES	20552	HCPCS	450	RC		outpatient	510	433.5	Regence Group Administrators	Default	Fee Schedule	494.7				48.59	494.7
INJ TRIGGER POINTS 1 -2 MUSCLES	20552	HCPCS	450	RC		outpatient	510	433.5	SelectHealth	Default	Percent of Total Billed Charges	484.5				48.59	494.7
ARTHROCENTESIS ASP INJ INTERMED JOINT	20605	HCPCS	450	RC		outpatient	280.5	238.43	Blue Cross of ID	Default	Percent of Total Billed Charges	272.08				50.92	272.08
ARTHROCENTESIS ASP INJ INTERMED JOINT	20605	HCPCS	450	RC		outpatient	280.5	238.43	Medicaid Idaho	Default	Fee Schedule	129.03				50.92	272.08
ARTHROCENTESIS ASP INJ INTERMED JOINT	20605	HCPCS	450	RC		outpatient	280.5	238.43	Medicare A ID JF	Default	Other	109.4		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	50.92	272.08
ARTHROCENTESIS ASP INJ INTERMED JOINT	20605	HCPCS	450	RC		outpatient	280.5	238.43	Medicare B ID JF	Default	Fee Schedule	50.92		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		50.92	272.08
ARTHROCENTESIS ASP INJ INTERMED JOINT	20605	HCPCS	450	RC		outpatient	280.5	238.43	Regence Group Administrators	Default	Fee Schedule	272.08				50.92	272.08
ARTHROCENTESIS ASP INJ INTERMED JOINT	20605	HCPCS	450	RC		outpatient	280.5	238.43	SelectHealth	Default	Percent of Total Billed Charges	266.48				50.92	272.08
ARTHRO ASPIR INJECT JOINT OR BURSA	20610	HCPCS	450	RC		outpatient	288	244.8	Blue Cross of ID	Default	Percent of Total Billed Charges	279.36				59.73	279.36
ARTHRO ASPIR INJECT JOINT OR BURSA	20610	HCPCS	450	RC		outpatient	288	244.8	Medicaid Idaho	Default	Fee Schedule	132.48				59.73	279.36
ARTHRO ASPIR INJECT JOINT OR BURSA	20610	HCPCS	450	RC		outpatient	288	244.8	Medicare A ID JF	Default	Other	112.32		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	59.73	279.36
ARTHRO ASPIR INJECT JOINT OR BURSA	20610	HCPCS	450	RC		outpatient	288	244.8	Medicare B ID JF	Default	Fee Schedule	59.73		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		59.73	279.36
ARTHRO ASPIR INJECT JOINT OR BURSA	20610	HCPCS	450	RC		outpatient	288	244.8	Regence Group Administrators	Default	Fee Schedule	279.36				59.73	279.36
ARTHRO ASPIR INJECT JOINT OR BURSA	20610	HCPCS	450	RC		outpatient	288	244.8	SelectHealth	Default	Percent of Total Billed Charges	273.6				59.73	279.36
REATTACH FINGERTIP	20822	HCPCS	450	RC		outpatient	1465.5	1245.68	Blue Cross of ID	Default	Percent of Total Billed Charges	1421.54				571.55	1465.5
REATTACH FINGERTIP	20822	HCPCS	450	RC		outpatient	1465.5	1245.68	Medicaid Idaho	Default	Fee Schedule	674.13				571.55	1465.5
REATTACH FINGERTIP	20822	HCPCS	450	RC		outpatient	1465.5	1245.68	Medicare A ID JF	Default	Other	571.55		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	571.55	1465.5
REATTACH FINGERTIP	20822	HCPCS	450	RC		outpatient	1465.5	1245.68	Medicare B ID JF	Default	Fee Schedule	1465.5		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		571.55	1465.5
REATTACH FINGERTIP	20822	HCPCS	450	RC		outpatient	1465.5	1245.68	Regence Group Administrators	Default	Fee Schedule	1421.54				571.55	1465.5
REATTACH FINGERTIP	20822	HCPCS	450	RC		outpatient	1465.5	1245.68	SelectHealth	Default	Percent of Total Billed Charges	1392.22				571.55	1465.5
CLOSED REDUCT NOSE	21315	HCPCS	450	RC		outpatient	1423.5	1209.98	Blue Cross of ID	Default	Percent of Total Billed Charges	1380.8				139.59	1380.8
CLOSED REDUCT NOSE	21315	HCPCS	450	RC		outpatient	1423.5	1209.98	Medicaid Idaho	Default	Fee Schedule	654.81				139.59	1380.8
CLOSED REDUCT NOSE	21315	HCPCS	450	RC		outpatient	1423.5	1209.98	Medicare A ID JF	Default	Other	555.17		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	139.59	1380.8
CLOSED REDUCT NOSE	21315	HCPCS	450	RC		outpatient	1423.5	1209.98	Medicare B ID JF	Default	Fee Schedule	139.59		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		139.59	1380.8
CLOSED REDUCT NOSE	21315	HCPCS	450	RC		outpatient	1423.5	1209.98	Regence Group Administrators	Default	Fee Schedule	1380.8				139.59	1380.8
CLOSED REDUCT NOSE	21315	HCPCS	450	RC		outpatient	1423.5	1209.98	SelectHealth	Default	Percent of Total Billed Charges	1352.32				139.59	1380.8
CLOSE TMJ DISLOC INIT OR SUB	21480	HCPCS	450	RC		outpatient	328	278.8	Blue Cross of ID	Default	Percent of Total Billed Charges	318.16				127.92	318.16
CLOSE TMJ DISLOC INIT OR SUB	21480	HCPCS	450	RC		outpatient	328	278.8	Medicaid Idaho	Default	Fee Schedule	150.88				127.92	318.16
CLOSE TMJ DISLOC INIT OR SUB	21480	HCPCS	450	RC		outpatient	328	278.8	Medicare A ID JF	Default	Other	127.92		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	127.92	318.16
CLOSE TMJ DISLOC INIT OR SUB	21480	HCPCS	450	RC		outpatient	328	278.8	Medicare B ID JF	Default	Fee Schedule	128.54		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		127.92	318.16
CLOSE TMJ DISLOC INIT OR SUB	21480	HCPCS	450	RC		outpatient	328	278.8	Regence Group Administrators	Default	Fee Schedule	318.16				127.92	318.16
CLOSE TMJ DISLOC INIT OR SUB	21480	HCPCS	450	RC		outpatient	328	278.8	SelectHealth	Default	Percent of Total Billed Charges	311.6				127.92	318.16
CLOSED TX OF CLAVICULAR FX WO MANIP	23500	HCPCS	450	RC		outpatient	475	403.75	Blue Cross of ID	Default	Percent of Total Billed Charges	460.75				185.25	460.75
CLOSED TX OF CLAVICULAR FX WO MANIP	23500	HCPCS	450	RC		outpatient	475	403.75	Medicaid Idaho	Default	Fee Schedule	218.5				185.25	460.75
CLOSED TX OF CLAVICULAR FX WO MANIP	23500	HCPCS	450	RC		outpatient	475	403.75	Medicare A ID JF	Default	Other	185.25		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	185.25	460.75
CLOSED TX OF CLAVICULAR FX WO MANIP	23500	HCPCS	450	RC		outpatient	475	403.75	Medicare B ID JF	Default	Fee Schedule	212.4		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		185.25	460.75
CLOSED TX OF CLAVICULAR FX WO MANIP	23500	HCPCS	450	RC		outpatient	475	403.75	Regence Group Administrators	Default	Fee Schedule	460.75				185.25	460.75
CLOSED TX OF CLAVICULAR FX WO MANIP	23500	HCPCS	450	RC		outpatient	475	403.75	SelectHealth	Default	Percent of Total Billed Charges	451.25				185.25	460.75
CLOSED TREAT CLAV FX WITH MANIP	23505	HCPCS	450	RC		outpatient	1465.5	1245.68	Blue Cross of ID	Default	Percent of Total Billed Charges	1421.54				340	1421.54
CLOSED TREAT CLAV FX WITH MANIP	23505	HCPCS	450	RC		outpatient	1465.5	1245.68	Medicaid Idaho	Default	Fee Schedule	674.13				340	1421.54
CLOSED TREAT CLAV FX WITH MANIP	23505	HCPCS	450	RC		outpatient	1465.5	1245.68	Medicare A ID JF	Default	Other	571.55		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	340	1421.54
CLOSED TREAT CLAV FX WITH MANIP	23505	HCPCS	450	RC		outpatient	1465.5	1245.68	Medicare B ID JF	Default	Fee Schedule	340		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		340	1421.54
CLOSED TREAT CLAV FX WITH MANIP	23505	HCPCS	450	RC		outpatient	1465.5	1245.68	Regence Group Administrators	Default	Fee Schedule	1421.54				340	1421.54
CLOSED TREAT CLAV FX WITH MANIP	23505	HCPCS	450	RC		outpatient	1465.5	1245.68	SelectHealth	Default	Percent of Total Billed Charges	1392.22				340	1421.54
CLOSED RED SHOULDER W MANIP WO ANES	23650	HCPCS	450	RC		outpatient	297.5	252.88	Blue Cross of ID	Default	Percent of Total Billed Charges	288.58				116.03	297.5
CLOSED RED SHOULDER W MANIP WO ANES	23650	HCPCS	450	RC		outpatient	297.5	252.88	Medicaid Idaho	Default	Fee Schedule	136.85				116.03	297.5
CLOSED RED SHOULDER W MANIP WO ANES	23650	HCPCS	450	RC		outpatient	297.5	252.88	Medicare A ID JF	Default	Other	116.03		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	116.03	297.5
CLOSED RED SHOULDER W MANIP WO ANES	23650	HCPCS	450	RC		outpatient	297.5	252.88	Medicare B ID JF	Default	Fee Schedule	297.5		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		116.03	297.5
CLOSED RED SHOULDER W MANIP WO ANES	23650	HCPCS	450	RC		outpatient	297.5	252.88	Regence Group Administrators	Default	Fee Schedule	288.58				116.03	297.5
CLOSED RED SHOULDER W MANIP WO ANES	23650	HCPCS	450	RC		outpatient	297.5	252.88	SelectHealth	Default	Percent of Total Billed Charges	282.62				116.03	297.5
CLSD TX SHOULDER DISLC W MANIP W ANESTH	23655	HCPCS	450	RC		outpatient	1360	1156	Blue Cross of ID	Default	Percent of Total Billed Charges	1319.2				380.98	1319.2
CLSD TX SHOULDER DISLC W MANIP W ANESTH	23655	HCPCS	450	RC		outpatient	1360	1156	Medicaid Idaho	Default	Fee Schedule	625.6				380.98	1319.2
CLSD TX SHOULDER DISLC W MANIP W ANESTH	23655	HCPCS	450	RC		outpatient	1360	1156	Medicare A ID JF	Default	Other	530.4		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	380.98	1319.2
CLSD TX SHOULDER DISLC W MANIP W ANESTH	23655	HCPCS	450	RC		outpatient	1360	1156	Medicare B ID JF	Default	Fee Schedule	380.98		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		380.98	1319.2
CLSD TX SHOULDER DISLC W MANIP W ANESTH	23655	HCPCS	450	RC		outpatient	1360	1156	Regence Group Administrators	Default	Fee Schedule	1319.2				380.98	1319.2
CLSD TX SHOULDER DISLC W MANIP W ANESTH	23655	HCPCS	450	RC		outpatient	1360	1156	SelectHealth	Default	Percent of Total Billed Charges	1292				380.98	1319.2
CLOSED ELBOW TX DISLOCATION WO ANES	24600	HCPCS	450	RC		outpatient	686.5	583.53	Blue Cross of ID	Default	Percent of Total Billed Charges	665.9				267.74	665.9
CLOSED ELBOW TX DISLOCATION WO ANES	24600	HCPCS	450	RC		outpatient	686.5	583.53	Medicaid Idaho	Default	Fee Schedule	315.79				267.74	665.9
CLOSED ELBOW TX DISLOCATION WO ANES	24600	HCPCS	450	RC		outpatient	686.5	583.53	Medicare A ID JF	Default	Other	267.74		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	267.74	665.9
CLOSED ELBOW TX DISLOCATION WO ANES	24600	HCPCS	450	RC		outpatient	686.5	583.53	Medicare B ID JF	Default	Fee Schedule	355.89		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		267.74	665.9
CLOSED ELBOW TX DISLOCATION WO ANES	24600	HCPCS	450	RC		outpatient	686.5	583.53	Regence Group Administrators	Default	Fee Schedule	665.9				267.74	665.9
CLOSED ELBOW TX DISLOCATION WO ANES	24600	HCPCS	450	RC		outpatient	686.5	583.53	SelectHealth	Default	Percent of Total Billed Charges	652.18				267.74	665.9
CLTX RDL HEAD SUBLXT CHLD ELBOW W MANI	24640	HCPCS	450	RC		outpatient	491	417.35	Blue Cross of ID	Default	Percent of Total Billed Charges	476.27				98	476.27
CLTX RDL HEAD SUBLXT CHLD ELBOW W MANI	24640	HCPCS	450	RC		outpatient	491	417.35	Medicaid Idaho	Default	Fee Schedule	225.86				98	476.27
CLTX RDL HEAD SUBLXT CHLD ELBOW W MANI	24640	HCPCS	450	RC		outpatient	491	417.35	Medicare A ID JF	Default	Other	191.49		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	98	476.27
CLTX RDL HEAD SUBLXT CHLD ELBOW W MANI	24640	HCPCS	450	RC		outpatient	491	417.35	Medicare B ID JF	Default	Fee Schedule	98		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		98	476.27
CLTX RDL HEAD SUBLXT CHLD ELBOW W MANI	24640	HCPCS	450	RC		outpatient	491	417.35	Regence Group Administrators	Default	Fee Schedule	476.27				98	476.27
CLTX RDL HEAD SUBLXT CHLD ELBOW W MANI	24640	HCPCS	450	RC		outpatient	491	417.35	SelectHealth	Default	Percent of Total Billed Charges	466.45				98	476.27
CLOSED TX ULNAR SHAFT FX W MANIP	25535	HCPCS	450	RC		outpatient	444.5	377.83	Blue Cross of ID	Default	Percent of Total Billed Charges	431.16				173.36	444.5
CLOSED TX ULNAR SHAFT FX W MANIP	25535	HCPCS	450	RC		outpatient	444.5	377.83	Medicaid Idaho	Default	Fee Schedule	204.47				173.36	444.5
CLOSED TX ULNAR SHAFT FX W MANIP	25535	HCPCS	450	RC		outpatient	444.5	377.83	Medicare A ID JF	Default	Other	173.36		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	173.36	444.5
CLOSED TX ULNAR SHAFT FX W MANIP	25535	HCPCS	450	RC		outpatient	444.5	377.83	Medicare B ID JF	Default	Fee Schedule	444.5		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		173.36	444.5
CLOSED TX ULNAR SHAFT FX W MANIP	25535	HCPCS	450	RC		outpatient	444.5	377.83	Regence Group Administrators	Default	Fee Schedule	431.16				173.36	444.5
CLOSED TX ULNAR SHAFT FX W MANIP	25535	HCPCS	450	RC		outpatient	444.5	377.83	SelectHealth	Default	Percent of Total Billed Charges	422.28				173.36	444.5
CLTX DSTL RDL FX/EPIPHYSL SEP W MAN	25605	HCPCS	450	RC		outpatient	1465.5	1245.68	Blue Cross of ID	Default	Percent of Total Billed Charges	1421.54				506.97	1421.54
CLTX DSTL RDL FX/EPIPHYSL SEP W MAN	25605	HCPCS	450	RC		outpatient	1465.5	1245.68	Medicaid Idaho	Default	Fee Schedule	674.13				506.97	1421.54
CLTX DSTL RDL FX/EPIPHYSL SEP W MAN	25605	HCPCS	450	RC		outpatient	1465.5	1245.68	Medicare A ID JF	Default	Other	571.55		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	506.97	1421.54
CLTX DSTL RDL FX/EPIPHYSL SEP W MAN	25605	HCPCS	450	RC		outpatient	1465.5	1245.68	Medicare B ID JF	Default	Fee Schedule	506.97		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		506.97	1421.54
CLTX DSTL RDL FX/EPIPHYSL SEP W MAN	25605	HCPCS	450	RC		outpatient	1465.5	1245.68	Regence Group Administrators	Default	Fee Schedule	1421.54				506.97	1421.54
CLTX DSTL RDL FX/EPIPHYSL SEP W MAN	25605	HCPCS	450	RC		outpatient	1465.5	1245.68	SelectHealth	Default	Percent of Total Billed Charges	1392.22				506.97	1421.54
CLOSED TX DISTL RADIOULNAR DSL W MANI	25675	HCPCS	450	RC		outpatient	706.5	600.53	Blue Cross of ID	Default	Percent of Total Billed Charges	685.3				275.54	685.3
CLOSED TX DISTL RADIOULNAR DSL W MANI	25675	HCPCS	450	RC		outpatient	706.5	600.53	Medicaid Idaho	Default	Fee Schedule	324.99				275.54	685.3
CLOSED TX DISTL RADIOULNAR DSL W MANI	25675	HCPCS	450	RC		outpatient	706.5	600.53	Medicare A ID JF	Default	Other	275.54		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	275.54	685.3
CLOSED TX DISTL RADIOULNAR DSL W MANI	25675	HCPCS	450	RC		outpatient	706.5	600.53	Medicare B ID JF	Default	Fee Schedule	430.36		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		275.54	685.3
CLOSED TX DISTL RADIOULNAR DSL W MANI	25675	HCPCS	450	RC		outpatient	706.5	600.53	Regence Group Administrators	Default	Fee Schedule	685.3				275.54	685.3
CLOSED TX DISTL RADIOULNAR DSL W MANI	25675	HCPCS	450	RC		outpatient	706.5	600.53	SelectHealth	Default	Percent of Total Billed Charges	671.18				275.54	685.3
CLOSED TX FINGER DISLOCATION	26770	HCPCS	450	RC		outpatient	444	377.4	Blue Cross of ID	Default	Percent of Total Billed Charges	430.68				173.16	430.68
CLOSED TX FINGER DISLOCATION	26770	HCPCS	450	RC		outpatient	444	377.4	Medicaid Idaho	Default	Fee Schedule	204.24				173.16	430.68
CLOSED TX FINGER DISLOCATION	26770	HCPCS	450	RC		outpatient	444	377.4	Medicare A ID JF	Default	Other	173.16		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	173.16	430.68
CLOSED TX FINGER DISLOCATION	26770	HCPCS	450	RC		outpatient	444	377.4	Medicare B ID JF	Default	Fee Schedule	274.86		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		173.16	430.68
CLOSED TX FINGER DISLOCATION	26770	HCPCS	450	RC		outpatient	444	377.4	Regence Group Administrators	Default	Fee Schedule	430.68				173.16	430.68
CLOSED TX FINGER DISLOCATION	26770	HCPCS	450	RC		outpatient	444	377.4	SelectHealth	Default	Percent of Total Billed Charges	421.8				173.16	430.68
CL TX  IPHAL JT DISLC W MAN W ANES	26775	HCPCS	450	RC		outpatient	970.5	824.93	Blue Cross of ID	Default	Percent of Total Billed Charges	941.38				374.51	941.38
CL TX  IPHAL JT DISLC W MAN W ANES	26775	HCPCS	450	RC		outpatient	970.5	824.93	Medicaid Idaho	Default	Fee Schedule	446.43				374.51	941.38
CL TX  IPHAL JT DISLC W MAN W ANES	26775	HCPCS	450	RC		outpatient	970.5	824.93	Medicare A ID JF	Default	Other	378.5		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	374.51	941.38
CL TX  IPHAL JT DISLC W MAN W ANES	26775	HCPCS	450	RC		outpatient	970.5	824.93	Medicare B ID JF	Default	Fee Schedule	374.51		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		374.51	941.38
CL TX  IPHAL JT DISLC W MAN W ANES	26775	HCPCS	450	RC		outpatient	970.5	824.93	Regence Group Administrators	Default	Fee Schedule	941.38				374.51	941.38
CL TX  IPHAL JT DISLC W MAN W ANES	26775	HCPCS	450	RC		outpatient	970.5	824.93	SelectHealth	Default	Percent of Total Billed Charges	921.98				374.51	941.38
CLTX HIP DISLOC TRAUMATIC WO ANES	27250	HCPCS	450	RC		outpatient	598.5	508.73	Blue Cross of ID	Default	Percent of Total Billed Charges	580.54				162.25	580.54
CLTX HIP DISLOC TRAUMATIC WO ANES	27250	HCPCS	450	RC		outpatient	598.5	508.73	Medicaid Idaho	Default	Fee Schedule	275.31				162.25	580.54
CLTX HIP DISLOC TRAUMATIC WO ANES	27250	HCPCS	450	RC		outpatient	598.5	508.73	Medicare A ID JF	Default	Other	233.42		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	162.25	580.54
CLTX HIP DISLOC TRAUMATIC WO ANES	27250	HCPCS	450	RC		outpatient	598.5	508.73	Medicare B ID JF	Default	Fee Schedule	162.25		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		162.25	580.54
CLTX HIP DISLOC TRAUMATIC WO ANES	27250	HCPCS	450	RC		outpatient	598.5	508.73	Regence Group Administrators	Default	Fee Schedule	580.54				162.25	580.54
CLTX HIP DISLOC TRAUMATIC WO ANES	27250	HCPCS	450	RC		outpatient	598.5	508.73	SelectHealth	Default	Percent of Total Billed Charges	568.58				162.25	580.54
CLTX HIP DISLOC TRMATC W ANES	27252	HCPCS	450	RC		outpatient	1477.5	1255.88	Blue Cross of ID	Default	Percent of Total Billed Charges	1433.18				576.23	1433.18
CLTX HIP DISLOC TRMATC W ANES	27252	HCPCS	450	RC		outpatient	1477.5	1255.88	Medicaid Idaho	Default	Fee Schedule	679.65				576.23	1433.18
CLTX HIP DISLOC TRMATC W ANES	27252	HCPCS	450	RC		outpatient	1477.5	1255.88	Medicare A ID JF	Default	Other	576.23		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	576.23	1433.18
CLTX HIP DISLOC TRMATC W ANES	27252	HCPCS	450	RC		outpatient	1477.5	1255.88	Medicare B ID JF	Default	Fee Schedule	686.26		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		576.23	1433.18
CLTX HIP DISLOC TRMATC W ANES	27252	HCPCS	450	RC		outpatient	1477.5	1255.88	Regence Group Administrators	Default	Fee Schedule	1433.18				576.23	1433.18
CLTX HIP DISLOC TRMATC W ANES	27252	HCPCS	450	RC		outpatient	1477.5	1255.88	SelectHealth	Default	Percent of Total Billed Charges	1403.62				576.23	1433.18
CLTX FEM FX DSTL END MED/LAT COND W MAN	27510	HCPCS	450	RC		outpatient	1465.5	1245.68	Blue Cross of ID	Default	Percent of Total Billed Charges	1421.54				571.55	1421.54
CLTX FEM FX DSTL END MED/LAT COND W MAN	27510	HCPCS	450	RC		outpatient	1465.5	1245.68	Medicaid Idaho	Default	Fee Schedule	674.13				571.55	1421.54
CLTX FEM FX DSTL END MED/LAT COND W MAN	27510	HCPCS	450	RC		outpatient	1465.5	1245.68	Medicare A ID JF	Default	Other	571.55		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	571.55	1421.54
CLTX FEM FX DSTL END MED/LAT COND W MAN	27510	HCPCS	450	RC		outpatient	1465.5	1245.68	Medicare B ID JF	Default	Fee Schedule	627.43		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		571.55	1421.54
CLTX FEM FX DSTL END MED/LAT COND W MAN	27510	HCPCS	450	RC		outpatient	1465.5	1245.68	Regence Group Administrators	Default	Fee Schedule	1421.54				571.55	1421.54
CLTX FEM FX DSTL END MED/LAT COND W MAN	27510	HCPCS	450	RC		outpatient	1465.5	1245.68	SelectHealth	Default	Percent of Total Billed Charges	1392.22				571.55	1421.54
CLTX PATEL DISL WO ANES	27560	HCPCS	450	RC		outpatient	523	444.55	Blue Cross of ID	Default	Percent of Total Billed Charges	507.31				203.97	507.31
CLTX PATEL DISL WO ANES	27560	HCPCS	450	RC		outpatient	523	444.55	Medicaid Idaho	Default	Fee Schedule	240.58				203.97	507.31
CLTX PATEL DISL WO ANES	27560	HCPCS	450	RC		outpatient	523	444.55	Medicare A ID JF	Default	Other	203.97		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	203.97	507.31
CLTX PATEL DISL WO ANES	27560	HCPCS	450	RC		outpatient	523	444.55	Medicare B ID JF	Default	Fee Schedule	352.74		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		203.97	507.31
CLTX PATEL DISL WO ANES	27560	HCPCS	450	RC		outpatient	523	444.55	Regence Group Administrators	Default	Fee Schedule	507.31				203.97	507.31
CLTX PATEL DISL WO ANES	27560	HCPCS	450	RC		outpatient	523	444.55	SelectHealth	Default	Percent of Total Billed Charges	496.85				203.97	507.31
CLTX TIBIAL SHAFT FX W MAN W/WO SKEL TRA	27752	HCPCS	450	RC		outpatient	1465.5	1245.68	Blue Cross of ID	Default	Percent of Total Billed Charges	1421.54				500.23	1421.54
CLTX TIBIAL SHAFT FX W MAN W/WO SKEL TRA	27752	HCPCS	450	RC		outpatient	1465.5	1245.68	Medicaid Idaho	Default	Fee Schedule	674.13				500.23	1421.54
CLTX TIBIAL SHAFT FX W MAN W/WO SKEL TRA	27752	HCPCS	450	RC		outpatient	1465.5	1245.68	Medicare A ID JF	Default	Other	571.55		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	500.23	1421.54
CLTX TIBIAL SHAFT FX W MAN W/WO SKEL TRA	27752	HCPCS	450	RC		outpatient	1465.5	1245.68	Medicare B ID JF	Default	Fee Schedule	500.23		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		500.23	1421.54
CLTX TIBIAL SHAFT FX W MAN W/WO SKEL TRA	27752	HCPCS	450	RC		outpatient	1465.5	1245.68	Regence Group Administrators	Default	Fee Schedule	1421.54				500.23	1421.54
CLTX TIBIAL SHAFT FX W MAN W/WO SKEL TRA	27752	HCPCS	450	RC		outpatient	1465.5	1245.68	SelectHealth	Default	Percent of Total Billed Charges	1392.22				500.23	1421.54
CLTX PROX FIBUL/SHFT FX W MANI	27781	HCPCS	450	RC		outpatient	902	766.7	Blue Cross of ID	Default	Percent of Total Billed Charges	874.94				351.78	874.94
CLTX PROX FIBUL/SHFT FX W MANI	27781	HCPCS	450	RC		outpatient	902	766.7	Medicaid Idaho	Default	Fee Schedule	414.92				351.78	874.94
CLTX PROX FIBUL/SHFT FX W MANI	27781	HCPCS	450	RC		outpatient	902	766.7	Medicare A ID JF	Default	Other	351.78		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	351.78	874.94
CLTX PROX FIBUL/SHFT FX W MANI	27781	HCPCS	450	RC		outpatient	902	766.7	Medicare B ID JF	Default	Fee Schedule	412.64		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		351.78	874.94
CLTX PROX FIBUL/SHFT FX W MANI	27781	HCPCS	450	RC		outpatient	902	766.7	Regence Group Administrators	Default	Fee Schedule	874.94				351.78	874.94
CLTX PROX FIBUL/SHFT FX W MANI	27781	HCPCS	450	RC		outpatient	902	766.7	SelectHealth	Default	Percent of Total Billed Charges	856.9				351.78	874.94
CLTX DSTL FIB FX LAT MALLS W MANI	27788	HCPCS	450	RC		outpatient	902	766.7	Blue Cross of ID	Default	Percent of Total Billed Charges	874.94				351.78	874.94
CLTX DSTL FIB FX LAT MALLS W MANI	27788	HCPCS	450	RC		outpatient	902	766.7	Medicaid Idaho	Default	Fee Schedule	414.92				351.78	874.94
CLTX DSTL FIB FX LAT MALLS W MANI	27788	HCPCS	450	RC		outpatient	902	766.7	Medicare A ID JF	Default	Other	351.78		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	351.78	874.94
CLTX DSTL FIB FX LAT MALLS W MANI	27788	HCPCS	450	RC		outpatient	902	766.7	Medicare B ID JF	Default	Fee Schedule	400.55		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		351.78	874.94
CLTX DSTL FIB FX LAT MALLS W MANI	27788	HCPCS	450	RC		outpatient	902	766.7	Regence Group Administrators	Default	Fee Schedule	874.94				351.78	874.94
CLTX DSTL FIB FX LAT MALLS W MANI	27788	HCPCS	450	RC		outpatient	902	766.7	SelectHealth	Default	Percent of Total Billed Charges	856.9				351.78	874.94
CLTX BIMALLEOLAR ANKLE FX W MANI	27810	HCPCS	450	RC		outpatient	1465.5	1245.68	Blue Cross of ID	Default	Percent of Total Billed Charges	1421.54				446.05	1421.54
CLTX BIMALLEOLAR ANKLE FX W MANI	27810	HCPCS	450	RC		outpatient	1465.5	1245.68	Medicaid Idaho	Default	Fee Schedule	674.13				446.05	1421.54
CLTX BIMALLEOLAR ANKLE FX W MANI	27810	HCPCS	450	RC		outpatient	1465.5	1245.68	Medicare A ID JF	Default	Other	571.55		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	446.05	1421.54
CLTX BIMALLEOLAR ANKLE FX W MANI	27810	HCPCS	450	RC		outpatient	1465.5	1245.68	Medicare B ID JF	Default	Fee Schedule	446.05		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		446.05	1421.54
CLTX BIMALLEOLAR ANKLE FX W MANI	27810	HCPCS	450	RC		outpatient	1465.5	1245.68	Regence Group Administrators	Default	Fee Schedule	1421.54				446.05	1421.54
CLTX BIMALLEOLAR ANKLE FX W MANI	27810	HCPCS	450	RC		outpatient	1465.5	1245.68	SelectHealth	Default	Percent of Total Billed Charges	1392.22				446.05	1421.54
CLTX ANKLE DISLO WO ANES	27840	HCPCS	450	RC		outpatient	668	567.8	Blue Cross of ID	Default	Percent of Total Billed Charges	647.96				260.52	647.96
CLTX ANKLE DISLO WO ANES	27840	HCPCS	450	RC		outpatient	668	567.8	Medicaid Idaho	Default	Fee Schedule	307.28				260.52	647.96
CLTX ANKLE DISLO WO ANES	27840	HCPCS	450	RC		outpatient	668	567.8	Medicare A ID JF	Default	Other	260.52		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	260.52	647.96
CLTX ANKLE DISLO WO ANES	27840	HCPCS	450	RC		outpatient	668	567.8	Medicare B ID JF	Default	Fee Schedule	362.88		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		260.52	647.96
CLTX ANKLE DISLO WO ANES	27840	HCPCS	450	RC		outpatient	668	567.8	Regence Group Administrators	Default	Fee Schedule	647.96				260.52	647.96
CLTX ANKLE DISLO WO ANES	27840	HCPCS	450	RC		outpatient	668	567.8	SelectHealth	Default	Percent of Total Billed Charges	634.6				260.52	647.96
CLTX ANKLE DISLC REQ ANES W WO PRQ SKEL	27842	HCPCS	450	RC		outpatient	1465.5	1245.68	Blue Cross of ID	Default	Percent of Total Billed Charges	1421.54				458.03	1421.54
CLTX ANKLE DISLC REQ ANES W WO PRQ SKEL	27842	HCPCS	450	RC		outpatient	1465.5	1245.68	Medicaid Idaho	Default	Fee Schedule	674.13				458.03	1421.54
CLTX ANKLE DISLC REQ ANES W WO PRQ SKEL	27842	HCPCS	450	RC		outpatient	1465.5	1245.68	Medicare A ID JF	Default	Other	571.55		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	458.03	1421.54
CLTX ANKLE DISLC REQ ANES W WO PRQ SKEL	27842	HCPCS	450	RC		outpatient	1465.5	1245.68	Medicare B ID JF	Default	Fee Schedule	458.03		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		458.03	1421.54
CLTX ANKLE DISLC REQ ANES W WO PRQ SKEL	27842	HCPCS	450	RC		outpatient	1465.5	1245.68	Regence Group Administrators	Default	Fee Schedule	1421.54				458.03	1421.54
CLTX ANKLE DISLC REQ ANES W WO PRQ SKEL	27842	HCPCS	450	RC		outpatient	1465.5	1245.68	SelectHealth	Default	Percent of Total Billed Charges	1392.22				458.03	1421.54
FB REMOVAL FOOT SUBCU	28190	HCPCS	450	RC		outpatient	668	567.8	Blue Cross of ID	Default	Percent of Total Billed Charges	647.96				221.4	647.96
FB REMOVAL FOOT SUBCU	28190	HCPCS	450	RC		outpatient	668	567.8	Medicaid Idaho	Default	Fee Schedule	307.28				221.4	647.96
FB REMOVAL FOOT SUBCU	28190	HCPCS	450	RC		outpatient	668	567.8	Medicare A ID JF	Default	Other	260.52		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	221.4	647.96
FB REMOVAL FOOT SUBCU	28190	HCPCS	450	RC		outpatient	668	567.8	Medicare B ID JF	Default	Fee Schedule	221.4		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		221.4	647.96
FB REMOVAL FOOT SUBCU	28190	HCPCS	450	RC		outpatient	668	567.8	Regence Group Administrators	Default	Fee Schedule	647.96				221.4	647.96
FB REMOVAL FOOT SUBCU	28190	HCPCS	450	RC		outpatient	668	567.8	SelectHealth	Default	Percent of Total Billed Charges	634.6				221.4	647.96
CLTX METATARSAL FX WO MANI	28470	HCPCS	450	RC		outpatient	541	459.85	Blue Cross of ID	Default	Percent of Total Billed Charges	524.77				206.53	524.77
CLTX METATARSAL FX WO MANI	28470	HCPCS	450	RC		outpatient	541	459.85	Medicaid Idaho	Default	Fee Schedule	248.86				206.53	524.77
CLTX METATARSAL FX WO MANI	28470	HCPCS	450	RC		outpatient	541	459.85	Medicare A ID JF	Default	Other	210.99		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	206.53	524.77
CLTX METATARSAL FX WO MANI	28470	HCPCS	450	RC		outpatient	541	459.85	Medicare B ID JF	Default	Fee Schedule	206.53		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		206.53	524.77
CLTX METATARSAL FX WO MANI	28470	HCPCS	450	RC		outpatient	541	459.85	Regence Group Administrators	Default	Fee Schedule	524.77				206.53	524.77
CLTX METATARSAL FX WO MANI	28470	HCPCS	450	RC		outpatient	541	459.85	SelectHealth	Default	Percent of Total Billed Charges	513.95				206.53	524.77
CLTX METATARSAL FX W MANI	28475	HCPCS	450	RC		outpatient	444	377.4	Blue Cross of ID	Default	Percent of Total Billed Charges	430.68				173.16	430.68
CLTX METATARSAL FX W MANI	28475	HCPCS	450	RC		outpatient	444	377.4	Medicaid Idaho	Default	Fee Schedule	204.24				173.16	430.68
CLTX METATARSAL FX W MANI	28475	HCPCS	450	RC		outpatient	444	377.4	Medicare A ID JF	Default	Other	173.16		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	173.16	430.68
CLTX METATARSAL FX W MANI	28475	HCPCS	450	RC		outpatient	444	377.4	Medicare B ID JF	Default	Fee Schedule	246.72		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		173.16	430.68
CLTX METATARSAL FX W MANI	28475	HCPCS	450	RC		outpatient	444	377.4	Regence Group Administrators	Default	Fee Schedule	430.68				173.16	430.68
CLTX METATARSAL FX W MANI	28475	HCPCS	450	RC		outpatient	444	377.4	SelectHealth	Default	Percent of Total Billed Charges	421.8				173.16	430.68
CLTX TOE FRACTURE	28515	HCPCS	450	RC		outpatient	541	459.85	Blue Cross of ID	Default	Percent of Total Billed Charges	524.77				156.4	524.77
CLTX TOE FRACTURE	28515	HCPCS	450	RC		outpatient	541	459.85	Medicaid Idaho	Default	Fee Schedule	248.86				156.4	524.77
CLTX TOE FRACTURE	28515	HCPCS	450	RC		outpatient	541	459.85	Medicare A ID JF	Default	Other	210.99		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	156.4	524.77
CLTX TOE FRACTURE	28515	HCPCS	450	RC		outpatient	541	459.85	Medicare B ID JF	Default	Fee Schedule	156.4		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		156.4	524.77
CLTX TOE FRACTURE	28515	HCPCS	450	RC		outpatient	541	459.85	Regence Group Administrators	Default	Fee Schedule	524.77				156.4	524.77
CLTX TOE FRACTURE	28515	HCPCS	450	RC		outpatient	541	459.85	SelectHealth	Default	Percent of Total Billed Charges	513.95				156.4	524.77
CLTX TOE DISLOCATION	28660	HCPCS	450	RC		outpatient	373	317.05	Blue Cross of ID	Default	Percent of Total Billed Charges	361.81				117.02	361.81
CLTX TOE DISLOCATION	28660	HCPCS	450	RC		outpatient	373	317.05	Medicaid Idaho	Default	Fee Schedule	171.58				117.02	361.81
CLTX TOE DISLOCATION	28660	HCPCS	450	RC		outpatient	373	317.05	Medicare A ID JF	Default	Other	145.47		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	117.02	361.81
CLTX TOE DISLOCATION	28660	HCPCS	450	RC		outpatient	373	317.05	Medicare B ID JF	Default	Fee Schedule	117.02		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		117.02	361.81
CLTX TOE DISLOCATION	28660	HCPCS	450	RC		outpatient	373	317.05	Regence Group Administrators	Default	Fee Schedule	361.81				117.02	361.81
CLTX TOE DISLOCATION	28660	HCPCS	450	RC		outpatient	373	317.05	SelectHealth	Default	Percent of Total Billed Charges	354.35				117.02	361.81
APPLIC LONG ARM CAST	29065	HCPCS	450	RC		outpatient	453	385.05	Blue Cross of ID	Default	Percent of Total Billed Charges	439.41				90.21	439.41
APPLIC LONG ARM CAST	29065	HCPCS	450	RC		outpatient	453	385.05	Medicaid Idaho	Default	Fee Schedule	208.38				90.21	439.41
APPLIC LONG ARM CAST	29065	HCPCS	450	RC		outpatient	453	385.05	Medicare A ID JF	Default	Other	176.67		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	90.21	439.41
APPLIC LONG ARM CAST	29065	HCPCS	450	RC		outpatient	453	385.05	Medicare B ID JF	Default	Fee Schedule	90.21		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		90.21	439.41
APPLIC LONG ARM CAST	29065	HCPCS	450	RC		outpatient	453	385.05	Regence Group Administrators	Default	Fee Schedule	439.41				90.21	439.41
APPLIC LONG ARM CAST	29065	HCPCS	450	RC		outpatient	453	385.05	SelectHealth	Default	Percent of Total Billed Charges	430.35				90.21	439.41
APPLICATION FOREARM CAST	29075	HCPCS	450	RC		outpatient	373.5	317.48	Blue Cross of ID	Default	Percent of Total Billed Charges	362.3				81.43	362.3
APPLICATION FOREARM CAST	29075	HCPCS	450	RC		outpatient	373.5	317.48	Medicaid Idaho	Default	Fee Schedule	171.81				81.43	362.3
APPLICATION FOREARM CAST	29075	HCPCS	450	RC		outpatient	373.5	317.48	Medicare A ID JF	Default	Other	145.67		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	81.43	362.3
APPLICATION FOREARM CAST	29075	HCPCS	450	RC		outpatient	373.5	317.48	Medicare B ID JF	Default	Fee Schedule	81.43		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		81.43	362.3
APPLICATION FOREARM CAST	29075	HCPCS	450	RC		outpatient	373.5	317.48	Regence Group Administrators	Default	Fee Schedule	362.3				81.43	362.3
APPLICATION FOREARM CAST	29075	HCPCS	450	RC		outpatient	373.5	317.48	SelectHealth	Default	Percent of Total Billed Charges	354.82				81.43	362.3
APPLICATION HAND/WRIST CAST	29085	HCPCS	450	RC		outpatient	393	334.05	Blue Cross of ID	Default	Percent of Total Billed Charges	381.21				89.45	381.21
APPLICATION HAND/WRIST CAST	29085	HCPCS	450	RC		outpatient	393	334.05	Medicaid Idaho	Default	Fee Schedule	180.78				89.45	381.21
APPLICATION HAND/WRIST CAST	29085	HCPCS	450	RC		outpatient	393	334.05	Medicare A ID JF	Default	Other	153.27		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	89.45	381.21
APPLICATION HAND/WRIST CAST	29085	HCPCS	450	RC		outpatient	393	334.05	Medicare B ID JF	Default	Fee Schedule	89.45		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		89.45	381.21
APPLICATION HAND/WRIST CAST	29085	HCPCS	450	RC		outpatient	393	334.05	Regence Group Administrators	Default	Fee Schedule	381.21				89.45	381.21
APPLICATION HAND/WRIST CAST	29085	HCPCS	450	RC		outpatient	393	334.05	SelectHealth	Default	Percent of Total Billed Charges	373.35				89.45	381.21
APPLICATION SPLINT LONG ARM	29105	HCPCS	450	RC		outpatient	364	309.4	Blue Cross of ID	Default	Percent of Total Billed Charges	353.08				76.84	353.08
APPLICATION SPLINT LONG ARM	29105	HCPCS	450	RC		outpatient	364	309.4	Medicaid Idaho	Default	Fee Schedule	167.44				76.84	353.08
APPLICATION SPLINT LONG ARM	29105	HCPCS	450	RC		outpatient	364	309.4	Medicare A ID JF	Default	Other	141.96		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	76.84	353.08
APPLICATION SPLINT LONG ARM	29105	HCPCS	450	RC		outpatient	364	309.4	Medicare B ID JF	Default	Fee Schedule	76.84		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		76.84	353.08
APPLICATION SPLINT LONG ARM	29105	HCPCS	450	RC		outpatient	364	309.4	Regence Group Administrators	Default	Fee Schedule	353.08				76.84	353.08
APPLICATION SPLINT LONG ARM	29105	HCPCS	450	RC		outpatient	364	309.4	SelectHealth	Default	Percent of Total Billed Charges	345.8				76.84	353.08
APPLICATION SPLINT FOREARM	29125	HCPCS	450	RC		outpatient	316	268.6	Blue Cross of ID	Default	Percent of Total Billed Charges	306.52				62.15	306.52
APPLICATION SPLINT FOREARM	29125	HCPCS	450	RC		outpatient	316	268.6	Medicaid Idaho	Default	Fee Schedule	145.36				62.15	306.52
APPLICATION SPLINT FOREARM	29125	HCPCS	450	RC		outpatient	316	268.6	Medicare A ID JF	Default	Other	123.24		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	62.15	306.52
APPLICATION SPLINT FOREARM	29125	HCPCS	450	RC		outpatient	316	268.6	Medicare B ID JF	Default	Fee Schedule	62.15		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		62.15	306.52
APPLICATION SPLINT FOREARM	29125	HCPCS	450	RC		outpatient	316	268.6	Regence Group Administrators	Default	Fee Schedule	306.52				62.15	306.52
APPLICATION SPLINT FOREARM	29125	HCPCS	450	RC		outpatient	316	268.6	SelectHealth	Default	Percent of Total Billed Charges	300.2				62.15	306.52
APPLICATION OF FINGER SPLINT	29130	HCPCS	450	RC		outpatient	167.5	142.38	Blue Cross of ID	Default	Percent of Total Billed Charges	162.48				38.88	162.48
APPLICATION OF FINGER SPLINT	29130	HCPCS	450	RC		outpatient	167.5	142.38	Medicaid Idaho	Default	Fee Schedule	77.05				38.88	162.48
APPLICATION OF FINGER SPLINT	29130	HCPCS	450	RC		outpatient	167.5	142.38	Medicare A ID JF	Default	Other	65.33		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	38.88	162.48
APPLICATION OF FINGER SPLINT	29130	HCPCS	450	RC		outpatient	167.5	142.38	Medicare B ID JF	Default	Fee Schedule	38.88		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		38.88	162.48
APPLICATION OF FINGER SPLINT	29130	HCPCS	450	RC		outpatient	167.5	142.38	Regence Group Administrators	Default	Fee Schedule	162.48				38.88	162.48
APPLICATION OF FINGER SPLINT	29130	HCPCS	450	RC		outpatient	167.5	142.38	SelectHealth	Default	Percent of Total Billed Charges	159.12				38.88	162.48
STRAPPING OF CHEST	29200	HCPCS	450	RC		outpatient	210.5	178.93	Blue Cross of ID	Default	Percent of Total Billed Charges	204.18				29.91	204.18
STRAPPING OF CHEST	29200	HCPCS	450	RC		outpatient	210.5	178.93	Medicaid Idaho	Default	Fee Schedule	96.83				29.91	204.18
STRAPPING OF CHEST	29200	HCPCS	450	RC		outpatient	210.5	178.93	Medicare A ID JF	Default	Other	82.1		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	29.91	204.18
STRAPPING OF CHEST	29200	HCPCS	450	RC		outpatient	210.5	178.93	Medicare B ID JF	Default	Fee Schedule	29.91		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		29.91	204.18
STRAPPING OF CHEST	29200	HCPCS	450	RC		outpatient	210.5	178.93	Regence Group Administrators	Default	Fee Schedule	204.18				29.91	204.18
STRAPPING OF CHEST	29200	HCPCS	450	RC		outpatient	210.5	178.93	SelectHealth	Default	Percent of Total Billed Charges	199.98				29.91	204.18
APPLICATION LONG LEG CAST THIGH TOES	29345	HCPCS	450	RC		outpatient	574	487.9	Blue Cross of ID	Default	Percent of Total Billed Charges	556.78				125.25	556.78
APPLICATION LONG LEG CAST THIGH TOES	29345	HCPCS	450	RC		outpatient	574	487.9	Medicaid Idaho	Default	Fee Schedule	264.04				125.25	556.78
APPLICATION LONG LEG CAST THIGH TOES	29345	HCPCS	450	RC		outpatient	574	487.9	Medicare A ID JF	Default	Other	223.86		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	125.25	556.78
APPLICATION LONG LEG CAST THIGH TOES	29345	HCPCS	450	RC		outpatient	574	487.9	Medicare B ID JF	Default	Fee Schedule	125.25		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		125.25	556.78
APPLICATION LONG LEG CAST THIGH TOES	29345	HCPCS	450	RC		outpatient	574	487.9	Regence Group Administrators	Default	Fee Schedule	556.78				125.25	556.78
APPLICATION LONG LEG CAST THIGH TOES	29345	HCPCS	450	RC		outpatient	574	487.9	SelectHealth	Default	Percent of Total Billed Charges	545.3				125.25	556.78
APPLICATION CAST SHORT LEG BELOW KNEE	29405	HCPCS	450	RC		outpatient	418.5	355.73	Blue Cross of ID	Default	Percent of Total Billed Charges	405.94				74.87	405.94
APPLICATION CAST SHORT LEG BELOW KNEE	29405	HCPCS	450	RC		outpatient	418.5	355.73	Medicaid Idaho	Default	Fee Schedule	192.51				74.87	405.94
APPLICATION CAST SHORT LEG BELOW KNEE	29405	HCPCS	450	RC		outpatient	418.5	355.73	Medicare A ID JF	Default	Other	163.22		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	74.87	405.94
APPLICATION CAST SHORT LEG BELOW KNEE	29405	HCPCS	450	RC		outpatient	418.5	355.73	Medicare B ID JF	Default	Fee Schedule	74.87		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		74.87	405.94
APPLICATION CAST SHORT LEG BELOW KNEE	29405	HCPCS	450	RC		outpatient	418.5	355.73	Regence Group Administrators	Default	Fee Schedule	405.94				74.87	405.94
APPLICATION CAST SHORT LEG BELOW KNEE	29405	HCPCS	450	RC		outpatient	418.5	355.73	SelectHealth	Default	Percent of Total Billed Charges	397.58				74.87	405.94
APPL SPLINT LONG LEG THIGH TO ANKLE	29505	HCPCS	450	RC		outpatient	338.5	287.73	Blue Cross of ID	Default	Percent of Total Billed Charges	328.34				83.45	328.34
APPL SPLINT LONG LEG THIGH TO ANKLE	29505	HCPCS	450	RC		outpatient	338.5	287.73	Medicaid Idaho	Default	Fee Schedule	155.71				83.45	328.34
APPL SPLINT LONG LEG THIGH TO ANKLE	29505	HCPCS	450	RC		outpatient	338.5	287.73	Medicare A ID JF	Default	Other	132.02		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	83.45	328.34
APPL SPLINT LONG LEG THIGH TO ANKLE	29505	HCPCS	450	RC		outpatient	338.5	287.73	Medicare B ID JF	Default	Fee Schedule	83.45		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		83.45	328.34
APPL SPLINT LONG LEG THIGH TO ANKLE	29505	HCPCS	450	RC		outpatient	338.5	287.73	Regence Group Administrators	Default	Fee Schedule	328.34				83.45	328.34
APPL SPLINT LONG LEG THIGH TO ANKLE	29505	HCPCS	450	RC		outpatient	338.5	287.73	SelectHealth	Default	Percent of Total Billed Charges	321.58				83.45	328.34
APPLICATION SPLINT LOWER LEG/ANKLE	29515	HCPCS	450	RC		outpatient	323	274.55	Blue Cross of ID	Default	Percent of Total Billed Charges	313.31				67.4	313.31
APPLICATION SPLINT LOWER LEG/ANKLE	29515	HCPCS	450	RC		outpatient	323	274.55	Medicaid Idaho	Default	Fee Schedule	148.58				67.4	313.31
APPLICATION SPLINT LOWER LEG/ANKLE	29515	HCPCS	450	RC		outpatient	323	274.55	Medicare A ID JF	Default	Other	125.97		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	67.4	313.31
APPLICATION SPLINT LOWER LEG/ANKLE	29515	HCPCS	450	RC		outpatient	323	274.55	Medicare B ID JF	Default	Fee Schedule	67.4		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		67.4	313.31
APPLICATION SPLINT LOWER LEG/ANKLE	29515	HCPCS	450	RC		outpatient	323	274.55	Regence Group Administrators	Default	Fee Schedule	313.31				67.4	313.31
APPLICATION SPLINT LOWER LEG/ANKLE	29515	HCPCS	450	RC		outpatient	323	274.55	SelectHealth	Default	Percent of Total Billed Charges	306.85				67.4	313.31
E&M LEVEL 5	99285	HCPCS	450	RC		outpatient	1614.5	1372.33	Blue Cross of ID	Default	Percent of Total Billed Charges	1566.06				163.17	1566.06
E&M LEVEL 5	99285	HCPCS	450	RC		outpatient	1614.5	1372.33	Medicaid Idaho	Default	Fee Schedule	742.67				163.17	1566.06
E&M LEVEL 5	99285	HCPCS	450	RC		outpatient	1614.5	1372.33	Medicare A ID JF	Default	Other	629.66		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	163.17	1566.06
E&M LEVEL 5	99285	HCPCS	450	RC		outpatient	1614.5	1372.33	Medicare B ID JF	Default	Fee Schedule	163.17		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		163.17	1566.06
E&M LEVEL 5	99285	HCPCS	450	RC		outpatient	1614.5	1372.33	Regence Group Administrators	Default	Fee Schedule	1566.06				163.17	1566.06
E&M LEVEL 5	99285	HCPCS	450	RC		outpatient	1614.5	1372.33	SelectHealth	Default	Percent of Total Billed Charges	1533.78				163.17	1566.06
ER DOPPLER	270	RC				both	232.5	197.63	Blue Cross of ID	Default	Percent of Total Billed Charges	225.52				90.68	225.52
ER DOPPLER	270	RC				both	232.5	197.63	Medicaid Idaho	Default	Fee Schedule	106.95				90.68	225.52
ER DOPPLER	270	RC				both	232.5	197.63	Medicare A ID JF	Default	Other	90.68		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	90.68	225.52
ER DOPPLER	270	RC				both	232.5	197.63	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		90.68	225.52
ER DOPPLER	270	RC				both	232.5	197.63	Regence Group Administrators	Default	Fee Schedule	225.52				90.68	225.52
ER DOPPLER	270	RC				both	232.5	197.63	SelectHealth	Default	Percent of Total Billed Charges	220.88				90.68	225.52
E&M LEVEL 1	99281	HCPCS	450	RC		outpatient	160	136	Blue Cross of ID	Default	Percent of Total Billed Charges	155.2				10.6	155.2
E&M LEVEL 1	99281	HCPCS	450	RC		outpatient	160	136	Medicaid Idaho	Default	Fee Schedule	73.6				10.6	155.2
E&M LEVEL 1	99281	HCPCS	450	RC		outpatient	160	136	Medicare A ID JF	Default	Other	62.4		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	10.6	155.2
E&M LEVEL 1	99281	HCPCS	450	RC		outpatient	160	136	Medicare B ID JF	Default	Fee Schedule	10.6		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		10.6	155.2
E&M LEVEL 1	99281	HCPCS	450	RC		outpatient	160	136	Regence Group Administrators	Default	Fee Schedule	155.2				10.6	155.2
E&M LEVEL 1	99281	HCPCS	450	RC		outpatient	160	136	SelectHealth	Default	Percent of Total Billed Charges	152				10.6	155.2
E&M LEVEL 2	99282	HCPCS	450	RC		outpatient	465.5	395.68	Blue Cross of ID	Default	Percent of Total Billed Charges	451.54				38.84	451.54
E&M LEVEL 2	99282	HCPCS	450	RC		outpatient	465.5	395.68	Medicaid Idaho	Default	Fee Schedule	214.13				38.84	451.54
E&M LEVEL 2	99282	HCPCS	450	RC		outpatient	465.5	395.68	Medicare A ID JF	Default	Other	181.55		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	38.84	451.54
E&M LEVEL 2	99282	HCPCS	450	RC		outpatient	465.5	395.68	Medicare B ID JF	Default	Fee Schedule	38.84		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		38.84	451.54
E&M LEVEL 2	99282	HCPCS	450	RC		outpatient	465.5	395.68	Regence Group Administrators	Default	Fee Schedule	451.54				38.84	451.54
E&M LEVEL 2	99282	HCPCS	450	RC		outpatient	465.5	395.68	SelectHealth	Default	Percent of Total Billed Charges	442.22				38.84	451.54
E&M LEVEL 3	99283	HCPCS	450	RC		outpatient	690	586.5	Blue Cross of ID	Default	Percent of Total Billed Charges	669.3				66.15	669.3
E&M LEVEL 3	99283	HCPCS	450	RC		outpatient	690	586.5	Medicaid Idaho	Default	Fee Schedule	317.4				66.15	669.3
E&M LEVEL 3	99283	HCPCS	450	RC		outpatient	690	586.5	Medicare A ID JF	Default	Other	269.1		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	66.15	669.3
E&M LEVEL 3	99283	HCPCS	450	RC		outpatient	690	586.5	Medicare B ID JF	Default	Fee Schedule	66.15		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		66.15	669.3
E&M LEVEL 3	99283	HCPCS	450	RC		outpatient	690	586.5	Regence Group Administrators	Default	Fee Schedule	669.3				66.15	669.3
E&M LEVEL 3	99283	HCPCS	450	RC		outpatient	690	586.5	SelectHealth	Default	Percent of Total Billed Charges	655.5				66.15	669.3
E&M LEVEL 4	99284	HCPCS	450	RC		outpatient	1220.5	1037.43	Blue Cross of ID	Default	Percent of Total Billed Charges	1183.88				112.58	1183.88
E&M LEVEL 4	99284	HCPCS	450	RC		outpatient	1220.5	1037.43	Medicaid Idaho	Default	Fee Schedule	561.43				112.58	1183.88
E&M LEVEL 4	99284	HCPCS	450	RC		outpatient	1220.5	1037.43	Medicare A ID JF	Default	Other	476		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	112.58	1183.88
E&M LEVEL 4	99284	HCPCS	450	RC		outpatient	1220.5	1037.43	Medicare B ID JF	Default	Fee Schedule	112.58		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		112.58	1183.88
E&M LEVEL 4	99284	HCPCS	450	RC		outpatient	1220.5	1037.43	Regence Group Administrators	Default	Fee Schedule	1183.88				112.58	1183.88
E&M LEVEL 4	99284	HCPCS	450	RC		outpatient	1220.5	1037.43	SelectHealth	Default	Percent of Total Billed Charges	1159.48				112.58	1183.88
RAPID RHINO ANTERIOR	270	RC				both	104.5	88.83	Blue Cross of ID	Default	Percent of Total Billed Charges	101.36				40.76	101.36
RAPID RHINO ANTERIOR	270	RC				both	104.5	88.83	Medicaid Idaho	Default	Fee Schedule	48.07				40.76	101.36
RAPID RHINO ANTERIOR	270	RC				both	104.5	88.83	Medicare A ID JF	Default	Other	40.76		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	40.76	101.36
RAPID RHINO ANTERIOR	270	RC				both	104.5	88.83	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		40.76	101.36
RAPID RHINO ANTERIOR	270	RC				both	104.5	88.83	Regence Group Administrators	Default	Fee Schedule	101.36				40.76	101.36
RAPID RHINO ANTERIOR	270	RC				both	104.5	88.83	SelectHealth	Default	Percent of Total Billed Charges	99.28				40.76	101.36
TRAY SUTURE	270	RC				both	125	106.25	Blue Cross of ID	Default	Percent of Total Billed Charges	121.25				48.75	121.25
TRAY SUTURE	270	RC				both	125	106.25	Medicaid Idaho	Default	Fee Schedule	57.5				48.75	121.25
TRAY SUTURE	270	RC				both	125	106.25	Medicare A ID JF	Default	Other	48.75		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	48.75	121.25
TRAY SUTURE	270	RC				both	125	106.25	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		48.75	121.25
TRAY SUTURE	270	RC				both	125	106.25	Regence Group Administrators	Default	Fee Schedule	121.25				48.75	121.25
TRAY SUTURE	270	RC				both	125	106.25	SelectHealth	Default	Percent of Total Billed Charges	118.75				48.75	121.25
REMOVAL FOREIGN BODY NOSE	30300	HCPCS	450	RC		outpatient	297	252.45	Blue Cross of ID	Default	Percent of Total Billed Charges	288.09				115.83	288.09
REMOVAL FOREIGN BODY NOSE	30300	HCPCS	450	RC		outpatient	297	252.45	Medicaid Idaho	Default	Fee Schedule	136.62				115.83	288.09
REMOVAL FOREIGN BODY NOSE	30300	HCPCS	450	RC		outpatient	297	252.45	Medicare A ID JF	Default	Other	115.83		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	115.83	288.09
REMOVAL FOREIGN BODY NOSE	30300	HCPCS	450	RC		outpatient	297	252.45	Medicare B ID JF	Default	Fee Schedule	192.58		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		115.83	288.09
REMOVAL FOREIGN BODY NOSE	30300	HCPCS	450	RC		outpatient	297	252.45	Regence Group Administrators	Default	Fee Schedule	288.09				115.83	288.09
REMOVAL FOREIGN BODY NOSE	30300	HCPCS	450	RC		outpatient	297	252.45	SelectHealth	Default	Percent of Total Billed Charges	282.15				115.83	288.09
NOSE BLEED SIMPLE	30901	HCPCS	450	RC		outpatient	323.5	274.98	Blue Cross of ID	Default	Percent of Total Billed Charges	313.8				126.17	313.8
NOSE BLEED SIMPLE	30901	HCPCS	450	RC		outpatient	323.5	274.98	Medicaid Idaho	Default	Fee Schedule	148.81				126.17	313.8
NOSE BLEED SIMPLE	30901	HCPCS	450	RC		outpatient	323.5	274.98	Medicare A ID JF	Default	Other	126.17		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	126.17	313.8
NOSE BLEED SIMPLE	30901	HCPCS	450	RC		outpatient	323.5	274.98	Medicare B ID JF	Default	Fee Schedule	142.6		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		126.17	313.8
NOSE BLEED SIMPLE	30901	HCPCS	450	RC		outpatient	323.5	274.98	Regence Group Administrators	Default	Fee Schedule	313.8				126.17	313.8
NOSE BLEED SIMPLE	30901	HCPCS	450	RC		outpatient	323.5	274.98	SelectHealth	Default	Percent of Total Billed Charges	307.32				126.17	313.8
NOSE BLEED COMPLEX ANTERIOR	30903	HCPCS	450	RC		outpatient	444	377.4	Blue Cross of ID	Default	Percent of Total Billed Charges	430.68				173.16	430.68
NOSE BLEED COMPLEX ANTERIOR	30903	HCPCS	450	RC		outpatient	444	377.4	Medicaid Idaho	Default	Fee Schedule	204.24				173.16	430.68
NOSE BLEED COMPLEX ANTERIOR	30903	HCPCS	450	RC		outpatient	444	377.4	Medicare A ID JF	Default	Other	173.16		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	173.16	430.68
NOSE BLEED COMPLEX ANTERIOR	30903	HCPCS	450	RC		outpatient	444	377.4	Medicare B ID JF	Default	Fee Schedule	222.09		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		173.16	430.68
NOSE BLEED COMPLEX ANTERIOR	30903	HCPCS	450	RC		outpatient	444	377.4	Regence Group Administrators	Default	Fee Schedule	430.68				173.16	430.68
NOSE BLEED COMPLEX ANTERIOR	30903	HCPCS	450	RC		outpatient	444	377.4	SelectHealth	Default	Percent of Total Billed Charges	421.8				173.16	430.68
NOSE BLEED COMPLEX POSTERIOR INITIAL	30905	HCPCS	450	RC		outpatient	459.5	390.58	Blue Cross of ID	Default	Percent of Total Billed Charges	445.72				179.21	445.72
NOSE BLEED COMPLEX POSTERIOR INITIAL	30905	HCPCS	450	RC		outpatient	459.5	390.58	Medicaid Idaho	Default	Fee Schedule	211.37				179.21	445.72
NOSE BLEED COMPLEX POSTERIOR INITIAL	30905	HCPCS	450	RC		outpatient	459.5	390.58	Medicare A ID JF	Default	Other	179.21		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	179.21	445.72
NOSE BLEED COMPLEX POSTERIOR INITIAL	30905	HCPCS	450	RC		outpatient	459.5	390.58	Medicare B ID JF	Default	Fee Schedule	318.49		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		179.21	445.72
NOSE BLEED COMPLEX POSTERIOR INITIAL	30905	HCPCS	450	RC		outpatient	459.5	390.58	Regence Group Administrators	Default	Fee Schedule	445.72				179.21	445.72
NOSE BLEED COMPLEX POSTERIOR INITIAL	30905	HCPCS	450	RC		outpatient	459.5	390.58	SelectHealth	Default	Percent of Total Billed Charges	436.52				179.21	445.72
SEXUAL ASSAULT RN EXAMINER	450	RC				outpatient	848.5	721.23	Blue Cross of ID	Default	Percent of Total Billed Charges	823.04				330.92	823.04
SEXUAL ASSAULT RN EXAMINER	450	RC				outpatient	848.5	721.23	Medicaid Idaho	Default	Fee Schedule	390.31				330.92	823.04
SEXUAL ASSAULT RN EXAMINER	450	RC				outpatient	848.5	721.23	Medicare A ID JF	Default	Other	330.92		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	330.92	823.04
SEXUAL ASSAULT RN EXAMINER	450	RC				outpatient	848.5	721.23	Medicare B ID JF	Default	Fee Schedule			"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		330.92	823.04
SEXUAL ASSAULT RN EXAMINER	450	RC				outpatient	848.5	721.23	Regence Group Administrators	Default	Fee Schedule	823.04				330.92	823.04
SEXUAL ASSAULT RN EXAMINER	450	RC				outpatient	848.5	721.23	SelectHealth	Default	Percent of Total Billed Charges	806.08				330.92	823.04
INSERT ENDOTRACHEAL TUBE	31500	HCPCS	450	RC		outpatient	887	753.95	Blue Cross of ID	Default	Percent of Total Billed Charges	860.39				128.83	860.39
INSERT ENDOTRACHEAL TUBE	31500	HCPCS	450	RC		outpatient	887	753.95	Medicaid Idaho	Default	Fee Schedule	408.02				128.83	860.39
INSERT ENDOTRACHEAL TUBE	31500	HCPCS	450	RC		outpatient	887	753.95	Medicare A ID JF	Default	Other	345.93		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	128.83	860.39
INSERT ENDOTRACHEAL TUBE	31500	HCPCS	450	RC		outpatient	887	753.95	Medicare B ID JF	Default	Fee Schedule	128.83		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		128.83	860.39
INSERT ENDOTRACHEAL TUBE	31500	HCPCS	450	RC		outpatient	887	753.95	Regence Group Administrators	Default	Fee Schedule	860.39				128.83	860.39
INSERT ENDOTRACHEAL TUBE	31500	HCPCS	450	RC		outpatient	887	753.95	SelectHealth	Default	Percent of Total Billed Charges	842.65				128.83	860.39
"ENDOSCOPE OF LARYNX, REM  FOREIGN BODY"	31511	HCPCS	450	RC		outpatient	471	400.35	Blue Cross of ID	Default	Percent of Total Billed Charges	456.87				183.69	456.87
"ENDOSCOPE OF LARYNX, REM  FOREIGN BODY"	31511	HCPCS	450	RC		outpatient	471	400.35	Medicaid Idaho	Default	Fee Schedule	216.66				183.69	456.87
"ENDOSCOPE OF LARYNX, REM  FOREIGN BODY"	31511	HCPCS	450	RC		outpatient	471	400.35	Medicare A ID JF	Default	Other	183.69		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	183.69	456.87
"ENDOSCOPE OF LARYNX, REM  FOREIGN BODY"	31511	HCPCS	450	RC		outpatient	471	400.35	Medicare B ID JF	Default	Fee Schedule	193.78		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		183.69	456.87
"ENDOSCOPE OF LARYNX, REM  FOREIGN BODY"	31511	HCPCS	450	RC		outpatient	471	400.35	Regence Group Administrators	Default	Fee Schedule	456.87				183.69	456.87
"ENDOSCOPE OF LARYNX, REM  FOREIGN BODY"	31511	HCPCS	450	RC		outpatient	471	400.35	SelectHealth	Default	Percent of Total Billed Charges	447.45				183.69	456.87
CHEST TUBE INSERTION HEMOTHORAX	32551	HCPCS	450	RC		outpatient	1479	1257.15	Blue Cross of ID	Default	Percent of Total Billed Charges	1434.63				140.16	1434.63
CHEST TUBE INSERTION HEMOTHORAX	32551	HCPCS	450	RC		outpatient	1479	1257.15	Medicaid Idaho	Default	Fee Schedule	680.34				140.16	1434.63
CHEST TUBE INSERTION HEMOTHORAX	32551	HCPCS	450	RC		outpatient	1479	1257.15	Medicare A ID JF	Default	Other	576.81		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	140.16	1434.63
CHEST TUBE INSERTION HEMOTHORAX	32551	HCPCS	450	RC		outpatient	1479	1257.15	Medicare B ID JF	Default	Fee Schedule	140.16		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		140.16	1434.63
CHEST TUBE INSERTION HEMOTHORAX	32551	HCPCS	450	RC		outpatient	1479	1257.15	Regence Group Administrators	Default	Fee Schedule	1434.63				140.16	1434.63
CHEST TUBE INSERTION HEMOTHORAX	32551	HCPCS	450	RC		outpatient	1479	1257.15	SelectHealth	Default	Percent of Total Billed Charges	1405.05				140.16	1434.63
INCISION AND DRAINAGE OF ABCESS	10060	HCPCS	982	RC		both	397	337.45	Blue Cross of ID	Default	Percent of Total Billed Charges	385.09				114	385.09
INCISION AND DRAINAGE OF ABCESS	10060	HCPCS	982	RC		both	397	337.45	Medicaid Idaho	Default	Fee Schedule	182.62				114	385.09
INCISION AND DRAINAGE OF ABCESS	10060	HCPCS	982	RC		both	397	337.45	Medicare A ID JF	Default	Other	114		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	114	385.09
INCISION AND DRAINAGE OF ABCESS	10060	HCPCS	982	RC		both	397	337.45	Medicare B ID JF	Default	Fee Schedule	117.56		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		114	385.09
INCISION AND DRAINAGE OF ABCESS	10060	HCPCS	982	RC		both	397	337.45	Regence Group Administrators	Default	Fee Schedule	385.09				114	385.09
INCISION AND DRAINAGE OF ABCESS	10060	HCPCS	982	RC		both	397	337.45	SelectHealth	Default	Percent of Total Billed Charges	377.15				114	385.09
I&D ABSCESS COMPLICATED/MULTIPLE	10061	HCPCS	981	RC		both	574	487.9	Blue Cross of ID	Default	Percent of Total Billed Charges	556.78				196.41	556.78
I&D ABSCESS COMPLICATED/MULTIPLE	10061	HCPCS	981	RC		both	574	487.9	Medicaid Idaho	Default	Fee Schedule	264.04				196.41	556.78
I&D ABSCESS COMPLICATED/MULTIPLE	10061	HCPCS	981	RC		both	574	487.9	Medicare A ID JF	Default	Other	196.41		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	196.41	556.78
I&D ABSCESS COMPLICATED/MULTIPLE	10061	HCPCS	981	RC		both	574	487.9	Medicare B ID JF	Default	Fee Schedule	198.3		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		196.41	556.78
I&D ABSCESS COMPLICATED/MULTIPLE	10061	HCPCS	981	RC		both	574	487.9	Regence Group Administrators	Default	Fee Schedule	556.78				196.41	556.78
I&D ABSCESS COMPLICATED/MULTIPLE	10061	HCPCS	981	RC		both	574	487.9	SelectHealth	Default	Percent of Total Billed Charges	545.3				196.41	556.78
FB REMOVAL SUBCU TISSUE SIMPLE	10120	HCPCS	450	RC		both	411.5	349.78	Blue Cross of ID	Default	Percent of Total Billed Charges	399.16				140.24	399.16
FB REMOVAL SUBCU TISSUE SIMPLE	10120	HCPCS	450	RC		both	411.5	349.78	Medicaid Idaho	Default	Fee Schedule	189.29				140.24	399.16
FB REMOVAL SUBCU TISSUE SIMPLE	10120	HCPCS	450	RC		both	411.5	349.78	Medicare A ID JF	Default	Other	160.49		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	140.24	399.16
FB REMOVAL SUBCU TISSUE SIMPLE	10120	HCPCS	450	RC		both	411.5	349.78	Medicare B ID JF	Default	Fee Schedule	140.24		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		140.24	399.16
FB REMOVAL SUBCU TISSUE SIMPLE	10120	HCPCS	450	RC		both	411.5	349.78	Regence Group Administrators	Default	Fee Schedule	399.16				140.24	399.16
FB REMOVAL SUBCU TISSUE SIMPLE	10120	HCPCS	450	RC		both	411.5	349.78	SelectHealth	Default	Percent of Total Billed Charges	390.92				140.24	399.16
INC & DRAIN HEMATOMA SIMPLE	10140	HCPCS	982	RC		both	471	400.35	Blue Cross of ID	Default	Percent of Total Billed Charges	456.87				126.06	456.87
INC & DRAIN HEMATOMA SIMPLE	10140	HCPCS	982	RC		both	471	400.35	Medicaid Idaho	Default	Fee Schedule	216.66				126.06	456.87
INC & DRAIN HEMATOMA SIMPLE	10140	HCPCS	982	RC		both	471	400.35	Medicare A ID JF	Default	Other	126.06		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	126.06	456.87
INC & DRAIN HEMATOMA SIMPLE	10140	HCPCS	982	RC		both	471	400.35	Medicare B ID JF	Default	Fee Schedule	156.47		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		126.06	456.87
INC & DRAIN HEMATOMA SIMPLE	10140	HCPCS	982	RC		both	471	400.35	Regence Group Administrators	Default	Fee Schedule	456.87				126.06	456.87
INC & DRAIN HEMATOMA SIMPLE	10140	HCPCS	982	RC		both	471	400.35	SelectHealth	Default	Percent of Total Billed Charges	447.45				126.06	456.87
PUNCTURE ASPIRATION ABSCESS ETC	10160	HCPCS	981	RC		both	340	289	Blue Cross of ID	Default	Percent of Total Billed Charges	329.8				102.81	329.8
PUNCTURE ASPIRATION ABSCESS ETC	10160	HCPCS	981	RC		both	340	289	Medicaid Idaho	Default	Fee Schedule	156.4				102.81	329.8
PUNCTURE ASPIRATION ABSCESS ETC	10160	HCPCS	981	RC		both	340	289	Medicare A ID JF	Default	Other	102.81		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	102.81	329.8
PUNCTURE ASPIRATION ABSCESS ETC	10160	HCPCS	981	RC		both	340	289	Medicare B ID JF	Default	Fee Schedule	119.63		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		102.81	329.8
PUNCTURE ASPIRATION ABSCESS ETC	10160	HCPCS	981	RC		both	340	289	Regence Group Administrators	Default	Fee Schedule	329.8				102.81	329.8
PUNCTURE ASPIRATION ABSCESS ETC	10160	HCPCS	981	RC		both	340	289	SelectHealth	Default	Percent of Total Billed Charges	323				102.81	329.8
DEBRDMNT REMOVAL OF FOREGN MATERIAL	11010	HCPCS	981	RC		both	1012.5	860.63	Blue Cross of ID	Default	Percent of Total Billed Charges	982.12				289.2	982.12
DEBRDMNT REMOVAL OF FOREGN MATERIAL	11010	HCPCS	981	RC		both	1012.5	860.63	Medicaid Idaho	Default	Fee Schedule	465.75				289.2	982.12
DEBRDMNT REMOVAL OF FOREGN MATERIAL	11010	HCPCS	981	RC		both	1012.5	860.63	Medicare A ID JF	Default	Other	289.2		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	289.2	982.12
DEBRDMNT REMOVAL OF FOREGN MATERIAL	11010	HCPCS	981	RC		both	1012.5	860.63	Medicare B ID JF	Default	Fee Schedule	408.05		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		289.2	982.12
DEBRDMNT REMOVAL OF FOREGN MATERIAL	11010	HCPCS	981	RC		both	1012.5	860.63	Regence Group Administrators	Default	Fee Schedule	982.12				289.2	982.12
DEBRDMNT REMOVAL OF FOREGN MATERIAL	11010	HCPCS	981	RC		both	1012.5	860.63	SelectHealth	Default	Percent of Total Billed Charges	961.88				289.2	982.12
"DEBRIDEMENT AT OPEN FRACTURE, SKIN/MUSCL"	11011	HCPCS	981	RC		both	846.5	719.53	Blue Cross of ID	Default	Percent of Total Billed Charges	821.1				309.45	821.1
"DEBRIDEMENT AT OPEN FRACTURE, SKIN/MUSCL"	11011	HCPCS	981	RC		both	846.5	719.53	Medicaid Idaho	Default	Fee Schedule	389.39				309.45	821.1
"DEBRIDEMENT AT OPEN FRACTURE, SKIN/MUSCL"	11011	HCPCS	981	RC		both	846.5	719.53	Medicare A ID JF	Default	Other	309.45		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	309.45	821.1
"DEBRIDEMENT AT OPEN FRACTURE, SKIN/MUSCL"	11011	HCPCS	981	RC		both	846.5	719.53	Medicare B ID JF	Default	Fee Schedule	454.37		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		309.45	821.1
"DEBRIDEMENT AT OPEN FRACTURE, SKIN/MUSCL"	11011	HCPCS	981	RC		both	846.5	719.53	Regence Group Administrators	Default	Fee Schedule	821.1				309.45	821.1
"DEBRIDEMENT AT OPEN FRACTURE, SKIN/MUSCL"	11011	HCPCS	981	RC		both	846.5	719.53	SelectHealth	Default	Percent of Total Billed Charges	804.18				309.45	821.1
DEBRIDEMENT AT SITE OF OPEN FRACTURE	11012	HCPCS	981	RC		both	1012.5	860.63	Blue Cross of ID	Default	Percent of Total Billed Charges	982.12				432.27	982.12
DEBRIDEMENT AT SITE OF OPEN FRACTURE	11012	HCPCS	981	RC		both	1012.5	860.63	Medicaid Idaho	Default	Fee Schedule	465.75				432.27	982.12
DEBRIDEMENT AT SITE OF OPEN FRACTURE	11012	HCPCS	981	RC		both	1012.5	860.63	Medicare A ID JF	Default	Other	432.27		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	432.27	982.12
DEBRIDEMENT AT SITE OF OPEN FRACTURE	11012	HCPCS	981	RC		both	1012.5	860.63	Medicare B ID JF	Default	Fee Schedule	591.7		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		432.27	982.12
DEBRIDEMENT AT SITE OF OPEN FRACTURE	11012	HCPCS	981	RC		both	1012.5	860.63	Regence Group Administrators	Default	Fee Schedule	982.12				432.27	982.12
DEBRIDEMENT AT SITE OF OPEN FRACTURE	11012	HCPCS	981	RC		both	1012.5	860.63	SelectHealth	Default	Percent of Total Billed Charges	961.88				432.27	982.12
"DEBRIDEMENT, 1ST 20 SQ CM OR LESS"	11043	HCPCS	981	RC		both	829.5	705.08	Blue Cross of ID	Default	Percent of Total Billed Charges	804.62				161.86	804.62
"DEBRIDEMENT, 1ST 20 SQ CM OR LESS"	11043	HCPCS	981	RC		both	829.5	705.08	Medicaid Idaho	Default	Fee Schedule	381.57				161.86	804.62
"DEBRIDEMENT, 1ST 20 SQ CM OR LESS"	11043	HCPCS	981	RC		both	829.5	705.08	Medicare A ID JF	Default	Other	161.86		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	161.86	804.62
"DEBRIDEMENT, 1ST 20 SQ CM OR LESS"	11043	HCPCS	981	RC		both	829.5	705.08	Medicare B ID JF	Default	Fee Schedule	213.59		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		161.86	804.62
"DEBRIDEMENT, 1ST 20 SQ CM OR LESS"	11043	HCPCS	981	RC		both	829.5	705.08	Regence Group Administrators	Default	Fee Schedule	804.62				161.86	804.62
"DEBRIDEMENT, 1ST 20 SQ CM OR LESS"	11043	HCPCS	981	RC		both	829.5	705.08	SelectHealth	Default	Percent of Total Billed Charges	788.02				161.86	804.62
"DEBRIDEMENT, ADDL 20 SQ CM OR PART"	11046	HCPCS	981	RC		both	162	137.7	Blue Cross of ID	Default	Percent of Total Billed Charges	157.14				57.03	157.14
"DEBRIDEMENT, ADDL 20 SQ CM OR PART"	11046	HCPCS	981	RC		both	162	137.7	Medicaid Idaho	Default	Fee Schedule	74.52				57.03	157.14
"DEBRIDEMENT, ADDL 20 SQ CM OR PART"	11046	HCPCS	981	RC		both	162	137.7	Medicare A ID JF	Default	Other	57.03		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	57.03	157.14
"DEBRIDEMENT, ADDL 20 SQ CM OR PART"	11046	HCPCS	981	RC		both	162	137.7	Medicare B ID JF	Default	Fee Schedule	66.52		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		57.03	157.14
"DEBRIDEMENT, ADDL 20 SQ CM OR PART"	11046	HCPCS	981	RC		both	162	137.7	Regence Group Administrators	Default	Fee Schedule	157.14				57.03	157.14
"DEBRIDEMENT, ADDL 20 SQ CM OR PART"	11046	HCPCS	981	RC		both	162	137.7	SelectHealth	Default	Percent of Total Billed Charges	153.9				57.03	157.14
BIOPSY SKIN SUBQ TISS ETC ONE LES	11100	HCPCS	981	RC		both	294	249.9	Blue Cross of ID	Default	Percent of Total Billed Charges	285.18				54.17	285.18
BIOPSY SKIN SUBQ TISS ETC ONE LES	11100	HCPCS	981	RC		both	294	249.9	Medicaid Idaho	Default	Fee Schedule	135.24				54.17	285.18
BIOPSY SKIN SUBQ TISS ETC ONE LES	11100	HCPCS	981	RC		both	294	249.9	Medicare A ID JF	Default	Other	54.17		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	54.17	285.18
BIOPSY SKIN SUBQ TISS ETC ONE LES	11100	HCPCS	981	RC		both	294	249.9	Medicare B ID JF	Default	Fee Schedule	98.73		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		54.17	285.18
BIOPSY SKIN SUBQ TISS ETC ONE LES	11100	HCPCS	981	RC		both	294	249.9	Regence Group Administrators	Default	Fee Schedule	285.18				54.17	285.18
BIOPSY SKIN SUBQ TISS ETC ONE LES	11100	HCPCS	981	RC		both	294	249.9	SelectHealth	Default	Percent of Total Billed Charges	279.3				54.17	285.18
REM SKIN/MULTI FIBRO TAGS TO 15	11200	HCPCS	981	RC		both	251.5	213.78	Blue Cross of ID	Default	Percent of Total Billed Charges	243.96				81.64	243.96
REM SKIN/MULTI FIBRO TAGS TO 15	11200	HCPCS	981	RC		both	251.5	213.78	Medicaid Idaho	Default	Fee Schedule	115.69				81.64	243.96
REM SKIN/MULTI FIBRO TAGS TO 15	11200	HCPCS	981	RC		both	251.5	213.78	Medicare A ID JF	Default	Other	81.64		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	81.64	243.96
REM SKIN/MULTI FIBRO TAGS TO 15	11200	HCPCS	981	RC		both	251.5	213.78	Medicare B ID JF	Default	Fee Schedule	85.5		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		81.64	243.96
REM SKIN/MULTI FIBRO TAGS TO 15	11200	HCPCS	981	RC		both	251.5	213.78	Regence Group Administrators	Default	Fee Schedule	243.96				81.64	243.96
REM SKIN/MULTI FIBRO TAGS TO 15	11200	HCPCS	981	RC		both	251.5	213.78	SelectHealth	Default	Percent of Total Billed Charges	238.92				81.64	243.96
SHAVE DERM LGS TRNK EXT TO 0.5 CM	11300	HCPCS	981	RC		both	144.5	122.83	Blue Cross of ID	Default	Percent of Total Billed Charges	140.16				36.02	140.16
SHAVE DERM LGS TRNK EXT TO 0.5 CM	11300	HCPCS	981	RC		both	144.5	122.83	Medicaid Idaho	Default	Fee Schedule	66.47				36.02	140.16
SHAVE DERM LGS TRNK EXT TO 0.5 CM	11300	HCPCS	981	RC		both	144.5	122.83	Medicare A ID JF	Default	Other	36.02		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	36.02	140.16
SHAVE DERM LGS TRNK EXT TO 0.5 CM	11300	HCPCS	981	RC		both	144.5	122.83	Medicare B ID JF	Default	Fee Schedule	92.08		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		36.02	140.16
SHAVE DERM LGS TRNK EXT TO 0.5 CM	11300	HCPCS	981	RC		both	144.5	122.83	Regence Group Administrators	Default	Fee Schedule	140.16				36.02	140.16
SHAVE DERM LGS TRNK EXT TO 0.5 CM	11300	HCPCS	981	RC		both	144.5	122.83	SelectHealth	Default	Percent of Total Billed Charges	137.28				36.02	140.16
SHAVE DERM LES TRNK EXT 0.6-1.0 CM	11301	HCPCS	981	RC		both	271.5	230.78	Blue Cross of ID	Default	Percent of Total Billed Charges	263.36				54.29	263.36
SHAVE DERM LES TRNK EXT 0.6-1.0 CM	11301	HCPCS	981	RC		both	271.5	230.78	Medicaid Idaho	Default	Fee Schedule	124.89				54.29	263.36
SHAVE DERM LES TRNK EXT 0.6-1.0 CM	11301	HCPCS	981	RC		both	271.5	230.78	Medicare A ID JF	Default	Other	54.29		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	54.29	263.36
SHAVE DERM LES TRNK EXT 0.6-1.0 CM	11301	HCPCS	981	RC		both	271.5	230.78	Medicare B ID JF	Default	Fee Schedule	111.59		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		54.29	263.36
SHAVE DERM LES TRNK EXT 0.6-1.0 CM	11301	HCPCS	981	RC		both	271.5	230.78	Regence Group Administrators	Default	Fee Schedule	263.36				54.29	263.36
SHAVE DERM LES TRNK EXT 0.6-1.0 CM	11301	HCPCS	981	RC		both	271.5	230.78	SelectHealth	Default	Percent of Total Billed Charges	257.92				54.29	263.36
SHAVE DERM LES TRNK EXT 1.1-2.0 CM	11302	HCPCS	981	RC		both	312	265.2	Blue Cross of ID	Default	Percent of Total Billed Charges	302.64				63.34	302.64
SHAVE DERM LES TRNK EXT 1.1-2.0 CM	11302	HCPCS	981	RC		both	312	265.2	Medicaid Idaho	Default	Fee Schedule	143.52				63.34	302.64
SHAVE DERM LES TRNK EXT 1.1-2.0 CM	11302	HCPCS	981	RC		both	312	265.2	Medicare A ID JF	Default	Other	63.34		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	63.34	302.64
SHAVE DERM LES TRNK EXT 1.1-2.0 CM	11302	HCPCS	981	RC		both	312	265.2	Medicare B ID JF	Default	Fee Schedule	126.11		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		63.34	302.64
SHAVE DERM LES TRNK EXT 1.1-2.0 CM	11302	HCPCS	981	RC		both	312	265.2	Regence Group Administrators	Default	Fee Schedule	302.64				63.34	302.64
SHAVE DERM LES TRNK EXT 1.1-2.0 CM	11302	HCPCS	981	RC		both	312	265.2	SelectHealth	Default	Percent of Total Billed Charges	296.4				63.34	302.64
EXC BENIGN LES TRNK/ARM/LEG TO .5 CM	11400	HCPCS	981	RC		both	265.5	225.68	Blue Cross of ID	Default	Percent of Total Billed Charges	257.54				89.75	257.54
EXC BENIGN LES TRNK/ARM/LEG TO .5 CM	11400	HCPCS	981	RC		both	265.5	225.68	Medicaid Idaho	Default	Fee Schedule	122.13				89.75	257.54
EXC BENIGN LES TRNK/ARM/LEG TO .5 CM	11400	HCPCS	981	RC		both	265.5	225.68	Medicare A ID JF	Default	Other	89.75		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	89.75	257.54
EXC BENIGN LES TRNK/ARM/LEG TO .5 CM	11400	HCPCS	981	RC		both	265.5	225.68	Medicare B ID JF	Default	Fee Schedule	117.94		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		89.75	257.54
EXC BENIGN LES TRNK/ARM/LEG TO .5 CM	11400	HCPCS	981	RC		both	265.5	225.68	Regence Group Administrators	Default	Fee Schedule	257.54				89.75	257.54
EXC BENIGN LES TRNK/ARM/LEG TO .5 CM	11400	HCPCS	981	RC		both	265.5	225.68	SelectHealth	Default	Percent of Total Billed Charges	252.22				89.75	257.54
EXC BEN LES TRNK/LIMB TO .5-1 CM	11401	HCPCS	981	RC		both	339.5	288.58	Blue Cross of ID	Default	Percent of Total Billed Charges	329.32				112.65	329.32
EXC BEN LES TRNK/LIMB TO .5-1 CM	11401	HCPCS	981	RC		both	339.5	288.58	Medicaid Idaho	Default	Fee Schedule	156.17				112.65	329.32
EXC BEN LES TRNK/LIMB TO .5-1 CM	11401	HCPCS	981	RC		both	339.5	288.58	Medicare A ID JF	Default	Other	112.65		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	112.65	329.32
EXC BEN LES TRNK/LIMB TO .5-1 CM	11401	HCPCS	981	RC		both	339.5	288.58	Medicare B ID JF	Default	Fee Schedule	143.9		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		112.65	329.32
EXC BEN LES TRNK/LIMB TO .5-1 CM	11401	HCPCS	981	RC		both	339.5	288.58	Regence Group Administrators	Default	Fee Schedule	329.32				112.65	329.32
EXC BEN LES TRNK/LIMB TO .5-1 CM	11401	HCPCS	981	RC		both	339.5	288.58	SelectHealth	Default	Percent of Total Billed Charges	322.52				112.65	329.32
"EXC LESION T,A,L 1.1-2.0CM"	11602	HCPCS	981	RC		both	338.5	287.73	Blue Cross of ID	Default	Percent of Total Billed Charges	328.34				155.71	328.34
"EXC LESION T,A,L 1.1-2.0CM"	11602	HCPCS	981	RC		both	338.5	287.73	Medicaid Idaho	Default	Fee Schedule	155.71				155.71	328.34
"EXC LESION T,A,L 1.1-2.0CM"	11602	HCPCS	981	RC		both	338.5	287.73	Medicare A ID JF	Default	Other	171.6		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	155.71	328.34
"EXC LESION T,A,L 1.1-2.0CM"	11602	HCPCS	981	RC		both	338.5	287.73	Medicare B ID JF	Default	Fee Schedule	225.99		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		155.71	328.34
"EXC LESION T,A,L 1.1-2.0CM"	11602	HCPCS	981	RC		both	338.5	287.73	Regence Group Administrators	Default	Fee Schedule	328.34				155.71	328.34
"EXC LESION T,A,L 1.1-2.0CM"	11602	HCPCS	981	RC		both	338.5	287.73	SelectHealth	Default	Percent of Total Billed Charges	321.58				155.71	328.34
EXC MAL LES FACE ADNEXA .5-1CM	11641	HCPCS	981	RC		both	727	617.95	Blue Cross of ID	Default	Percent of Total Billed Charges	705.19				165	705.19
EXC MAL LES FACE ADNEXA .5-1CM	11641	HCPCS	981	RC		both	727	617.95	Medicaid Idaho	Default	Fee Schedule	334.42				165	705.19
EXC MAL LES FACE ADNEXA .5-1CM	11641	HCPCS	981	RC		both	727	617.95	Medicare A ID JF	Default	Other	165		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	165	705.19
EXC MAL LES FACE ADNEXA .5-1CM	11641	HCPCS	981	RC		both	727	617.95	Medicare B ID JF	Default	Fee Schedule	218.43		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		165	705.19
EXC MAL LES FACE ADNEXA .5-1CM	11641	HCPCS	981	RC		both	727	617.95	Regence Group Administrators	Default	Fee Schedule	705.19				165	705.19
EXC MAL LES FACE ADNEXA .5-1CM	11641	HCPCS	981	RC		both	727	617.95	SelectHealth	Default	Percent of Total Billed Charges	690.65				165	705.19
"SIMPLE REPAIR SCALP, NCK, AXILLAE 2.5 <"	12001	HCPCS	981	RC		both	335.5	285.18	Blue Cross of ID	Default	Percent of Total Billed Charges	325.44				46.79	325.44
"SIMPLE REPAIR SCALP, NCK, AXILLAE 2.5 <"	12001	HCPCS	981	RC		both	335.5	285.18	Medicaid Idaho	Default	Fee Schedule	154.33				46.79	325.44
"SIMPLE REPAIR SCALP, NCK, AXILLAE 2.5 <"	12001	HCPCS	981	RC		both	335.5	285.18	Medicare A ID JF	Default	Other	46.79		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	46.79	325.44
"SIMPLE REPAIR SCALP, NCK, AXILLAE 2.5 <"	12001	HCPCS	981	RC		both	335.5	285.18	Medicare B ID JF	Default	Fee Schedule	86.03		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		46.79	325.44
"SIMPLE REPAIR SCALP, NCK, AXILLAE 2.5 <"	12001	HCPCS	981	RC		both	335.5	285.18	Regence Group Administrators	Default	Fee Schedule	325.44				46.79	325.44
"SIMPLE REPAIR SCALP, NCK, AXILLAE 2.5 <"	12001	HCPCS	981	RC		both	335.5	285.18	SelectHealth	Default	Percent of Total Billed Charges	318.72				46.79	325.44
SIMPLE REPAIR SCALP NCK 2.6 CM TO 7.5 CM	12002	HCPCS	981	RC		both	410	348.5	Blue Cross of ID	Default	Percent of Total Billed Charges	397.7				61.42	397.7
SIMPLE REPAIR SCALP NCK 2.6 CM TO 7.5 CM	12002	HCPCS	981	RC		both	410	348.5	Medicaid Idaho	Default	Fee Schedule	188.6				61.42	397.7
SIMPLE REPAIR SCALP NCK 2.6 CM TO 7.5 CM	12002	HCPCS	981	RC		both	410	348.5	Medicare A ID JF	Default	Other	61.42		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	61.42	397.7
SIMPLE REPAIR SCALP NCK 2.6 CM TO 7.5 CM	12002	HCPCS	981	RC		both	410	348.5	Medicare B ID JF	Default	Fee Schedule	104.19		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		61.42	397.7
SIMPLE REPAIR SCALP NCK 2.6 CM TO 7.5 CM	12002	HCPCS	981	RC		both	410	348.5	Regence Group Administrators	Default	Fee Schedule	397.7				61.42	397.7
SIMPLE REPAIR SCALP NCK 2.6 CM TO 7.5 CM	12002	HCPCS	981	RC		both	410	348.5	SelectHealth	Default	Percent of Total Billed Charges	389.5				61.42	397.7
LAC SIMPLE 7.6 TO 12.5	12004	HCPCS	981	RC		both	529	449.65	Blue Cross of ID	Default	Percent of Total Billed Charges	513.13				76.58	513.13
LAC SIMPLE 7.6 TO 12.5	12004	HCPCS	981	RC		both	529	449.65	Medicaid Idaho	Default	Fee Schedule	243.34				76.58	513.13
LAC SIMPLE 7.6 TO 12.5	12004	HCPCS	981	RC		both	529	449.65	Medicare A ID JF	Default	Other	76.58		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	76.58	513.13
LAC SIMPLE 7.6 TO 12.5	12004	HCPCS	981	RC		both	529	449.65	Medicare B ID JF	Default	Fee Schedule	121.3		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		76.58	513.13
LAC SIMPLE 7.6 TO 12.5	12004	HCPCS	981	RC		both	529	449.65	Regence Group Administrators	Default	Fee Schedule	513.13				76.58	513.13
LAC SIMPLE 7.6 TO 12.5	12004	HCPCS	981	RC		both	529	449.65	SelectHealth	Default	Percent of Total Billed Charges	502.55				76.58	513.13
REP SIMPLE SCALP ETC 12.6-20.0 CM	12005	HCPCS	981	RC		both	667.5	567.38	Blue Cross of ID	Default	Percent of Total Billed Charges	647.48				98.46	647.48
REP SIMPLE SCALP ETC 12.6-20.0 CM	12005	HCPCS	981	RC		both	667.5	567.38	Medicaid Idaho	Default	Fee Schedule	307.05				98.46	647.48
REP SIMPLE SCALP ETC 12.6-20.0 CM	12005	HCPCS	981	RC		both	667.5	567.38	Medicare A ID JF	Default	Other	98.46		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	98.46	647.48
REP SIMPLE SCALP ETC 12.6-20.0 CM	12005	HCPCS	981	RC		both	667.5	567.38	Medicare B ID JF	Default	Fee Schedule	161.48		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		98.46	647.48
REP SIMPLE SCALP ETC 12.6-20.0 CM	12005	HCPCS	981	RC		both	667.5	567.38	Regence Group Administrators	Default	Fee Schedule	647.48				98.46	647.48
REP SIMPLE SCALP ETC 12.6-20.0 CM	12005	HCPCS	981	RC		both	667.5	567.38	SelectHealth	Default	Percent of Total Billed Charges	634.12				98.46	647.48
SIMPLE RPR FACE EARS EYES ETC 2.5 <	12011	HCPCS	981	RC		both	410	348.5	Blue Cross of ID	Default	Percent of Total Billed Charges	397.7				57.88	397.7
SIMPLE RPR FACE EARS EYES ETC 2.5 <	12011	HCPCS	981	RC		both	410	348.5	Medicaid Idaho	Default	Fee Schedule	188.6				57.88	397.7
SIMPLE RPR FACE EARS EYES ETC 2.5 <	12011	HCPCS	981	RC		both	410	348.5	Medicare A ID JF	Default	Other	57.88		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	57.88	397.7
SIMPLE RPR FACE EARS EYES ETC 2.5 <	12011	HCPCS	981	RC		both	410	348.5	Medicare B ID JF	Default	Fee Schedule	102.31		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		57.88	397.7
SIMPLE RPR FACE EARS EYES ETC 2.5 <	12011	HCPCS	981	RC		both	410	348.5	Regence Group Administrators	Default	Fee Schedule	397.7				57.88	397.7
SIMPLE RPR FACE EARS EYES ETC 2.5 <	12011	HCPCS	981	RC		both	410	348.5	SelectHealth	Default	Percent of Total Billed Charges	389.5				57.88	397.7
SIMPLE RPR FACE EAR EYE 2.6 CM TO 5.0 CM	12013	HCPCS	981	RC		both	454.5	386.33	Blue Cross of ID	Default	Percent of Total Billed Charges	440.86				60.32	440.86
SIMPLE RPR FACE EAR EYE 2.6 CM TO 5.0 CM	12013	HCPCS	981	RC		both	454.5	386.33	Medicaid Idaho	Default	Fee Schedule	209.07				60.32	440.86
SIMPLE RPR FACE EAR EYE 2.6 CM TO 5.0 CM	12013	HCPCS	981	RC		both	454.5	386.33	Medicare A ID JF	Default	Other	60.32		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	60.32	440.86
SIMPLE RPR FACE EAR EYE 2.6 CM TO 5.0 CM	12013	HCPCS	981	RC		both	454.5	386.33	Medicare B ID JF	Default	Fee Schedule	106.56		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		60.32	440.86
SIMPLE RPR FACE EAR EYE 2.6 CM TO 5.0 CM	12013	HCPCS	981	RC		both	454.5	386.33	Regence Group Administrators	Default	Fee Schedule	440.86				60.32	440.86
SIMPLE RPR FACE EAR EYE 2.6 CM TO 5.0 CM	12013	HCPCS	981	RC		both	454.5	386.33	SelectHealth	Default	Percent of Total Billed Charges	431.78				60.32	440.86
SIMP RPR FACE EAR ETC 5.1-7.5 CM	12014	HCPCS	981	RC		both	545	463.25	Blue Cross of ID	Default	Percent of Total Billed Charges	528.65				77.91	528.65
SIMP RPR FACE EAR ETC 5.1-7.5 CM	12014	HCPCS	981	RC		both	545	463.25	Medicaid Idaho	Default	Fee Schedule	250.7				77.91	528.65
SIMP RPR FACE EAR ETC 5.1-7.5 CM	12014	HCPCS	981	RC		both	545	463.25	Medicare A ID JF	Default	Other	77.91		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	77.91	528.65
SIMP RPR FACE EAR ETC 5.1-7.5 CM	12014	HCPCS	981	RC		both	545	463.25	Medicare B ID JF	Default	Fee Schedule	130.01		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		77.91	528.65
SIMP RPR FACE EAR ETC 5.1-7.5 CM	12014	HCPCS	981	RC		both	545	463.25	Regence Group Administrators	Default	Fee Schedule	528.65				77.91	528.65
SIMP RPR FACE EAR ETC 5.1-7.5 CM	12014	HCPCS	981	RC		both	545	463.25	SelectHealth	Default	Percent of Total Billed Charges	517.75				77.91	528.65
SIMP REP FACE EAR EYE ETC 7.5-12.5 CM	12015	HCPCS	981	RC		both	552	469.2	Blue Cross of ID	Default	Percent of Total Billed Charges	535.44				97.8	535.44
SIMP REP FACE EAR EYE ETC 7.5-12.5 CM	12015	HCPCS	981	RC		both	552	469.2	Medicaid Idaho	Default	Fee Schedule	253.92				97.8	535.44
SIMP REP FACE EAR EYE ETC 7.5-12.5 CM	12015	HCPCS	981	RC		both	552	469.2	Medicare A ID JF	Default	Other	97.8		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	97.8	535.44
SIMP REP FACE EAR EYE ETC 7.5-12.5 CM	12015	HCPCS	981	RC		both	552	469.2	Medicare B ID JF	Default	Fee Schedule	156.98		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		97.8	535.44
SIMP REP FACE EAR EYE ETC 7.5-12.5 CM	12015	HCPCS	981	RC		both	552	469.2	Regence Group Administrators	Default	Fee Schedule	535.44				97.8	535.44
SIMP REP FACE EAR EYE ETC 7.5-12.5 CM	12015	HCPCS	981	RC		both	552	469.2	SelectHealth	Default	Percent of Total Billed Charges	524.4				97.8	535.44
REP INTMD SCLP AX TRNK EXT X HA FT 2.5 <	12031	HCPCS	981	RC		both	557.5	473.88	Blue Cross of ID	Default	Percent of Total Billed Charges	540.78				160.57	540.78
REP INTMD SCLP AX TRNK EXT X HA FT 2.5 <	12031	HCPCS	981	RC		both	557.5	473.88	Medicaid Idaho	Default	Fee Schedule	256.45				160.57	540.78
REP INTMD SCLP AX TRNK EXT X HA FT 2.5 <	12031	HCPCS	981	RC		both	557.5	473.88	Medicare A ID JF	Default	Other	160.57		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	160.57	540.78
REP INTMD SCLP AX TRNK EXT X HA FT 2.5 <	12031	HCPCS	981	RC		both	557.5	473.88	Medicare B ID JF	Default	Fee Schedule	241.49		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		160.57	540.78
REP INTMD SCLP AX TRNK EXT X HA FT 2.5 <	12031	HCPCS	981	RC		both	557.5	473.88	Regence Group Administrators	Default	Fee Schedule	540.78				160.57	540.78
REP INTMD SCLP AX TRNK EXT X HA FT 2.5 <	12031	HCPCS	981	RC		both	557.5	473.88	SelectHealth	Default	Percent of Total Billed Charges	529.62				160.57	540.78
INT RPR SCLP TRNK EXTRM 2.6-7.5 CM	12032	HCPCS	981	RC		both	495	420.75	Blue Cross of ID	Default	Percent of Total Billed Charges	480.15				202.04	480.15
INT RPR SCLP TRNK EXTRM 2.6-7.5 CM	12032	HCPCS	981	RC		both	495	420.75	Medicaid Idaho	Default	Fee Schedule	227.7				202.04	480.15
INT RPR SCLP TRNK EXTRM 2.6-7.5 CM	12032	HCPCS	981	RC		both	495	420.75	Medicare A ID JF	Default	Other	202.04		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	202.04	480.15
INT RPR SCLP TRNK EXTRM 2.6-7.5 CM	12032	HCPCS	981	RC		both	495	420.75	Medicare B ID JF	Default	Fee Schedule	279.66		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		202.04	480.15
INT RPR SCLP TRNK EXTRM 2.6-7.5 CM	12032	HCPCS	981	RC		both	495	420.75	Regence Group Administrators	Default	Fee Schedule	480.15				202.04	480.15
INT RPR SCLP TRNK EXTRM 2.6-7.5 CM	12032	HCPCS	981	RC		both	495	420.75	SelectHealth	Default	Percent of Total Billed Charges	470.25				202.04	480.15
REP INTME SCALP ETC 7.6-12.5 CM	12034	HCPCS	981	RC		both	713.5	606.48	Blue Cross of ID	Default	Percent of Total Billed Charges	692.1				217.38	692.1
REP INTME SCALP ETC 7.6-12.5 CM	12034	HCPCS	981	RC		both	713.5	606.48	Medicaid Idaho	Default	Fee Schedule	328.21				217.38	692.1
REP INTME SCALP ETC 7.6-12.5 CM	12034	HCPCS	981	RC		both	713.5	606.48	Medicare A ID JF	Default	Other	217.38		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	217.38	692.1
REP INTME SCALP ETC 7.6-12.5 CM	12034	HCPCS	981	RC		both	713.5	606.48	Medicare B ID JF	Default	Fee Schedule	307.51		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		217.38	692.1
REP INTME SCALP ETC 7.6-12.5 CM	12034	HCPCS	981	RC		both	713.5	606.48	Regence Group Administrators	Default	Fee Schedule	692.1				217.38	692.1
REP INTME SCALP ETC 7.6-12.5 CM	12034	HCPCS	981	RC		both	713.5	606.48	SelectHealth	Default	Percent of Total Billed Charges	677.82				217.38	692.1
LAC MED S/A/T/E 12.6-20CM	12035	HCPCS	981	RC		both	745.5	633.68	Blue Cross of ID	Default	Percent of Total Billed Charges	723.14				253.2	723.14
LAC MED S/A/T/E 12.6-20CM	12035	HCPCS	981	RC		both	745.5	633.68	Medicaid Idaho	Default	Fee Schedule	342.93				253.2	723.14
LAC MED S/A/T/E 12.6-20CM	12035	HCPCS	981	RC		both	745.5	633.68	Medicare A ID JF	Default	Other	253.2		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	253.2	723.14
LAC MED S/A/T/E 12.6-20CM	12035	HCPCS	981	RC		both	745.5	633.68	Medicare B ID JF	Default	Fee Schedule	355.28		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		253.2	723.14
LAC MED S/A/T/E 12.6-20CM	12035	HCPCS	981	RC		both	745.5	633.68	Regence Group Administrators	Default	Fee Schedule	723.14				253.2	723.14
LAC MED S/A/T/E 12.6-20CM	12035	HCPCS	981	RC		both	745.5	633.68	SelectHealth	Default	Percent of Total Billed Charges	708.22				253.2	723.14
REP INTMD SCALP ETC 20.0-30CM	12036	HCPCS	981	RC		both	583.5	495.98	Blue Cross of ID	Default	Percent of Total Billed Charges	566				268.41	566
REP INTMD SCALP ETC 20.0-30CM	12036	HCPCS	981	RC		both	583.5	495.98	Medicaid Idaho	Default	Fee Schedule	268.41				268.41	566
REP INTMD SCALP ETC 20.0-30CM	12036	HCPCS	981	RC		both	583.5	495.98	Medicare A ID JF	Default	Other	294.25		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	268.41	566
REP INTMD SCALP ETC 20.0-30CM	12036	HCPCS	981	RC		both	583.5	495.98	Medicare B ID JF	Default	Fee Schedule	394.3		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		268.41	566
REP INTMD SCALP ETC 20.0-30CM	12036	HCPCS	981	RC		both	583.5	495.98	Regence Group Administrators	Default	Fee Schedule	566				268.41	566
REP INTMD SCALP ETC 20.0-30CM	12036	HCPCS	981	RC		both	583.5	495.98	SelectHealth	Default	Percent of Total Billed Charges	554.32				268.41	566
REP INTMD N-HF/GENIT 2.5 CM <	12041	HCPCS	981	RC		both	567	481.95	Blue Cross of ID	Default	Percent of Total Billed Charges	549.99				154.15	549.99
REP INTMD N-HF/GENIT 2.5 CM <	12041	HCPCS	981	RC		both	567	481.95	Medicaid Idaho	Default	Fee Schedule	260.82				154.15	549.99
REP INTMD N-HF/GENIT 2.5 CM <	12041	HCPCS	981	RC		both	567	481.95	Medicare A ID JF	Default	Other	154.15		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	154.15	549.99
REP INTMD N-HF/GENIT 2.5 CM <	12041	HCPCS	981	RC		both	567	481.95	Medicare B ID JF	Default	Fee Schedule	242.25		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		154.15	549.99
REP INTMD N-HF/GENIT 2.5 CM <	12041	HCPCS	981	RC		both	567	481.95	Regence Group Administrators	Default	Fee Schedule	549.99				154.15	549.99
REP INTMD N-HF/GENIT 2.5 CM <	12041	HCPCS	981	RC		both	567	481.95	SelectHealth	Default	Percent of Total Billed Charges	538.65				154.15	549.99
LAC MED N/H/F/G 2.6-7.5CM	12042	HCPCS	981	RC		both	544.5	462.83	Blue Cross of ID	Default	Percent of Total Billed Charges	528.16				207.86	528.16
LAC MED N/H/F/G 2.6-7.5CM	12042	HCPCS	981	RC		both	544.5	462.83	Medicaid Idaho	Default	Fee Schedule	250.47				207.86	528.16
LAC MED N/H/F/G 2.6-7.5CM	12042	HCPCS	981	RC		both	544.5	462.83	Medicare A ID JF	Default	Other	207.86		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	207.86	528.16
LAC MED N/H/F/G 2.6-7.5CM	12042	HCPCS	981	RC		both	544.5	462.83	Medicare B ID JF	Default	Fee Schedule	285.63		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		207.86	528.16
LAC MED N/H/F/G 2.6-7.5CM	12042	HCPCS	981	RC		both	544.5	462.83	Regence Group Administrators	Default	Fee Schedule	528.16				207.86	528.16
LAC MED N/H/F/G 2.6-7.5CM	12042	HCPCS	981	RC		both	544.5	462.83	SelectHealth	Default	Percent of Total Billed Charges	517.28				207.86	528.16
REP INTERMED NECK ETC 7.5-12.5CM	12044	HCPCS	981	RC		both	386.5	328.53	Blue Cross of ID	Default	Percent of Total Billed Charges	374.9				177.79	374.9
REP INTERMED NECK ETC 7.5-12.5CM	12044	HCPCS	981	RC		both	386.5	328.53	Medicaid Idaho	Default	Fee Schedule	177.79				177.79	374.9
REP INTERMED NECK ETC 7.5-12.5CM	12044	HCPCS	981	RC		both	386.5	328.53	Medicare A ID JF	Default	Other	226.69		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	177.79	374.9
REP INTERMED NECK ETC 7.5-12.5CM	12044	HCPCS	981	RC		both	386.5	328.53	Medicare B ID JF	Default	Fee Schedule	350.96		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		177.79	374.9
REP INTERMED NECK ETC 7.5-12.5CM	12044	HCPCS	981	RC		both	386.5	328.53	Regence Group Administrators	Default	Fee Schedule	374.9				177.79	374.9
REP INTERMED NECK ETC 7.5-12.5CM	12044	HCPCS	981	RC		both	386.5	328.53	SelectHealth	Default	Percent of Total Billed Charges	367.18				177.79	374.9
LAC MED FACE/EAR <2.5CM	12052	HCPCS	981	RC		both	505	429.25	Blue Cross of ID	Default	Percent of Total Billed Charges	489.85				211.62	489.85
LAC MED FACE/EAR <2.5CM	12052	HCPCS	981	RC		both	505	429.25	Medicaid Idaho	Default	Fee Schedule	232.3				211.62	489.85
LAC MED FACE/EAR <2.5CM	12052	HCPCS	981	RC		both	505	429.25	Medicare A ID JF	Default	Other	211.62		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	211.62	489.85
LAC MED FACE/EAR <2.5CM	12052	HCPCS	981	RC		both	505	429.25	Medicare B ID JF	Default	Fee Schedule	290.42		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		211.62	489.85
LAC MED FACE/EAR <2.5CM	12052	HCPCS	981	RC		both	505	429.25	Regence Group Administrators	Default	Fee Schedule	489.85				211.62	489.85
LAC MED FACE/EAR <2.5CM	12052	HCPCS	981	RC		both	505	429.25	SelectHealth	Default	Percent of Total Billed Charges	479.75				211.62	489.85
INT RPR FACE NOSE LIP 2.6-5.0 CM	12052	HCPCS	981	RC		both	668.5	568.23	Blue Cross of ID	Default	Percent of Total Billed Charges	648.44				211.62	648.44
INT RPR FACE NOSE LIP 2.6-5.0 CM	12052	HCPCS	981	RC		both	668.5	568.23	Medicaid Idaho	Default	Fee Schedule	307.51				211.62	648.44
INT RPR FACE NOSE LIP 2.6-5.0 CM	12052	HCPCS	981	RC		both	668.5	568.23	Medicare A ID JF	Default	Other	211.62		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	211.62	648.44
INT RPR FACE NOSE LIP 2.6-5.0 CM	12052	HCPCS	981	RC		both	668.5	568.23	Medicare B ID JF	Default	Fee Schedule	290.42		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		211.62	648.44
INT RPR FACE NOSE LIP 2.6-5.0 CM	12052	HCPCS	981	RC		both	668.5	568.23	Regence Group Administrators	Default	Fee Schedule	648.44				211.62	648.44
INT RPR FACE NOSE LIP 2.6-5.0 CM	12052	HCPCS	981	RC		both	668.5	568.23	SelectHealth	Default	Percent of Total Billed Charges	635.08				211.62	648.44
INT RPR FACE NOSE LIP 7.6-12.5 CM	12054	HCPCS	981	RC		both	778.5	661.73	Blue Cross of ID	Default	Percent of Total Billed Charges	755.14				232.48	755.14
INT RPR FACE NOSE LIP 7.6-12.5 CM	12054	HCPCS	981	RC		both	778.5	661.73	Medicaid Idaho	Default	Fee Schedule	358.11				232.48	755.14
INT RPR FACE NOSE LIP 7.6-12.5 CM	12054	HCPCS	981	RC		both	778.5	661.73	Medicare A ID JF	Default	Other	232.48		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	232.48	755.14
INT RPR FACE NOSE LIP 7.6-12.5 CM	12054	HCPCS	981	RC		both	778.5	661.73	Medicare B ID JF	Default	Fee Schedule	350.87		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		232.48	755.14
INT RPR FACE NOSE LIP 7.6-12.5 CM	12054	HCPCS	981	RC		both	778.5	661.73	Regence Group Administrators	Default	Fee Schedule	755.14				232.48	755.14
INT RPR FACE NOSE LIP 7.6-12.5 CM	12054	HCPCS	981	RC		both	778.5	661.73	SelectHealth	Default	Percent of Total Billed Charges	739.58				232.48	755.14
REP COMPLEX SCLP/LMB 2.6-7.5 CM	13121	HCPCS	981	RC		both	1036	880.6	Blue Cross of ID	Default	Percent of Total Billed Charges	1004.92				272.99	1004.92
REP COMPLEX SCLP/LMB 2.6-7.5 CM	13121	HCPCS	981	RC		both	1036	880.6	Medicaid Idaho	Default	Fee Schedule	476.56				272.99	1004.92
REP COMPLEX SCLP/LMB 2.6-7.5 CM	13121	HCPCS	981	RC		both	1036	880.6	Medicare A ID JF	Default	Other	272.99		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	272.99	1004.92
REP COMPLEX SCLP/LMB 2.6-7.5 CM	13121	HCPCS	981	RC		both	1036	880.6	Medicare B ID JF	Default	Fee Schedule	390.93		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		272.99	1004.92
REP COMPLEX SCLP/LMB 2.6-7.5 CM	13121	HCPCS	981	RC		both	1036	880.6	Regence Group Administrators	Default	Fee Schedule	1004.92				272.99	1004.92
REP COMPLEX SCLP/LMB 2.6-7.5 CM	13121	HCPCS	981	RC		both	1036	880.6	SelectHealth	Default	Percent of Total Billed Charges	984.2				272.99	1004.92
"REP CMPLX SCLP/ARMS/LEG, EA AD 5 CM OR >"	13122	HCPCS	981	RC		both	448.5	381.23	Blue Cross of ID	Default	Percent of Total Billed Charges	435.04				86.47	435.04
"REP CMPLX SCLP/ARMS/LEG, EA AD 5 CM OR >"	13122	HCPCS	981	RC		both	448.5	381.23	Medicaid Idaho	Default	Fee Schedule	206.31				86.47	435.04
"REP CMPLX SCLP/ARMS/LEG, EA AD 5 CM OR >"	13122	HCPCS	981	RC		both	448.5	381.23	Medicare A ID JF	Default	Other	86.47		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	86.47	435.04
"REP CMPLX SCLP/ARMS/LEG, EA AD 5 CM OR >"	13122	HCPCS	981	RC		both	448.5	381.23	Medicare B ID JF	Default	Fee Schedule	115.99		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		86.47	435.04
"REP CMPLX SCLP/ARMS/LEG, EA AD 5 CM OR >"	13122	HCPCS	981	RC		both	448.5	381.23	Regence Group Administrators	Default	Fee Schedule	435.04				86.47	435.04
"REP CMPLX SCLP/ARMS/LEG, EA AD 5 CM OR >"	13122	HCPCS	981	RC		both	448.5	381.23	SelectHealth	Default	Percent of Total Billed Charges	426.08				86.47	435.04
REP CMPLX FACE HANDS 2.5-7.5CM	13132	HCPCS	981	RC		both	866.5	736.53	Blue Cross of ID	Default	Percent of Total Billed Charges	840.5				320.25	840.5
REP CMPLX FACE HANDS 2.5-7.5CM	13132	HCPCS	981	RC		both	866.5	736.53	Medicaid Idaho	Default	Fee Schedule	398.59				320.25	840.5
REP CMPLX FACE HANDS 2.5-7.5CM	13132	HCPCS	981	RC		both	866.5	736.53	Medicare A ID JF	Default	Other	320.25		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	320.25	840.5
REP CMPLX FACE HANDS 2.5-7.5CM	13132	HCPCS	981	RC		both	866.5	736.53	Medicare B ID JF	Default	Fee Schedule	433.23		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		320.25	840.5
REP CMPLX FACE HANDS 2.5-7.5CM	13132	HCPCS	981	RC		both	866.5	736.53	Regence Group Administrators	Default	Fee Schedule	840.5				320.25	840.5
REP CMPLX FACE HANDS 2.5-7.5CM	13132	HCPCS	981	RC		both	866.5	736.53	SelectHealth	Default	Percent of Total Billed Charges	823.18				320.25	840.5
REP CMPLX FACIAL ADN 1.1-2.5 CM	13151	HCPCS	981	RC		both	986	838.1	Blue Cross of ID	Default	Percent of Total Billed Charges	956.42				293.85	956.42
REP CMPLX FACIAL ADN 1.1-2.5 CM	13151	HCPCS	981	RC		both	986	838.1	Medicaid Idaho	Default	Fee Schedule	453.56				293.85	956.42
REP CMPLX FACIAL ADN 1.1-2.5 CM	13151	HCPCS	981	RC		both	986	838.1	Medicare A ID JF	Default	Other	293.85		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	293.85	956.42
REP CMPLX FACIAL ADN 1.1-2.5 CM	13151	HCPCS	981	RC		both	986	838.1	Medicare B ID JF	Default	Fee Schedule	388.81		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		293.85	956.42
REP CMPLX FACIAL ADN 1.1-2.5 CM	13151	HCPCS	981	RC		both	986	838.1	Regence Group Administrators	Default	Fee Schedule	956.42				293.85	956.42
REP CMPLX FACIAL ADN 1.1-2.5 CM	13151	HCPCS	981	RC		both	986	838.1	SelectHealth	Default	Percent of Total Billed Charges	936.7				293.85	956.42
CAUTERIZATION CHEMICAL WOUND	17250	HCPCS	981	RC		both	225	191.25	Blue Cross of ID	Default	Percent of Total Billed Charges	218.25				39.68	218.25
CAUTERIZATION CHEMICAL WOUND	17250	HCPCS	981	RC		both	225	191.25	Medicaid Idaho	Default	Fee Schedule	103.5				39.68	218.25
CAUTERIZATION CHEMICAL WOUND	17250	HCPCS	981	RC		both	225	191.25	Medicare A ID JF	Default	Other	39.68		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	39.68	218.25
CAUTERIZATION CHEMICAL WOUND	17250	HCPCS	981	RC		both	225	191.25	Medicare B ID JF	Default	Fee Schedule	79.53		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		39.68	218.25
CAUTERIZATION CHEMICAL WOUND	17250	HCPCS	981	RC		both	225	191.25	Regence Group Administrators	Default	Fee Schedule	218.25				39.68	218.25
CAUTERIZATION CHEMICAL WOUND	17250	HCPCS	981	RC		both	225	191.25	SelectHealth	Default	Percent of Total Billed Charges	213.75				39.68	218.25
EXPLORATION OF EXTREMITY	20103	HCPCS	981	RC		both	724.5	615.83	Blue Cross of ID	Default	Percent of Total Billed Charges	702.76				333.27	702.76
EXPLORATION OF EXTREMITY	20103	HCPCS	981	RC		both	724.5	615.83	Medicaid Idaho	Default	Fee Schedule	333.27				333.27	702.76
EXPLORATION OF EXTREMITY	20103	HCPCS	981	RC		both	724.5	615.83	Medicare A ID JF	Default	Other	361.97		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	333.27	702.76
EXPLORATION OF EXTREMITY	20103	HCPCS	981	RC		both	724.5	615.83	Medicare B ID JF	Default	Fee Schedule	513.64		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		333.27	702.76
EXPLORATION OF EXTREMITY	20103	HCPCS	981	RC		both	724.5	615.83	Regence Group Administrators	Default	Fee Schedule	702.76				333.27	702.76
EXPLORATION OF EXTREMITY	20103	HCPCS	981	RC		both	724.5	615.83	SelectHealth	Default	Percent of Total Billed Charges	688.28				333.27	702.76
TRIGGER POINT INJECT/ONE OR TWO MUSCLES	20552	HCPCS	981	RC		both	321.5	273.28	Blue Cross of ID	Default	Percent of Total Billed Charges	311.86				39.19	311.86
TRIGGER POINT INJECT/ONE OR TWO MUSCLES	20552	HCPCS	981	RC		both	321.5	273.28	Medicaid Idaho	Default	Fee Schedule	147.89				39.19	311.86
TRIGGER POINT INJECT/ONE OR TWO MUSCLES	20552	HCPCS	981	RC		both	321.5	273.28	Medicare A ID JF	Default	Other	39.19		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	39.19	311.86
TRIGGER POINT INJECT/ONE OR TWO MUSCLES	20552	HCPCS	981	RC		both	321.5	273.28	Medicare B ID JF	Default	Fee Schedule	48.59		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		39.19	311.86
TRIGGER POINT INJECT/ONE OR TWO MUSCLES	20552	HCPCS	981	RC		both	321.5	273.28	Regence Group Administrators	Default	Fee Schedule	311.86				39.19	311.86
TRIGGER POINT INJECT/ONE OR TWO MUSCLES	20552	HCPCS	981	RC		both	321.5	273.28	SelectHealth	Default	Percent of Total Billed Charges	305.42				39.19	311.86
ARTHOCENTESIS SMALL JOINT	20600	HCPCS	981	RC		both	245	208.25	Blue Cross of ID	Default	Percent of Total Billed Charges	237.65				37.97	237.65
ARTHOCENTESIS SMALL JOINT	20600	HCPCS	981	RC		both	245	208.25	Medicaid Idaho	Default	Fee Schedule	112.7				37.97	237.65
ARTHOCENTESIS SMALL JOINT	20600	HCPCS	981	RC		both	245	208.25	Medicare A ID JF	Default	Other	37.97		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	37.97	237.65
ARTHOCENTESIS SMALL JOINT	20600	HCPCS	981	RC		both	245	208.25	Medicare B ID JF	Default	Fee Schedule	49.65		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		37.97	237.65
ARTHOCENTESIS SMALL JOINT	20600	HCPCS	981	RC		both	245	208.25	Regence Group Administrators	Default	Fee Schedule	237.65				37.97	237.65
ARTHOCENTESIS SMALL JOINT	20600	HCPCS	981	RC		both	245	208.25	SelectHealth	Default	Percent of Total Billed Charges	232.75				37.97	237.65
ARTHOCENTESIS INTERNEDIATE JOINT	20605	HCPCS	981	RC		both	276.5	235.03	Blue Cross of ID	Default	Percent of Total Billed Charges	268.2				39.09	268.2
ARTHOCENTESIS INTERNEDIATE JOINT	20605	HCPCS	981	RC		both	276.5	235.03	Medicaid Idaho	Default	Fee Schedule	127.19				39.09	268.2
ARTHOCENTESIS INTERNEDIATE JOINT	20605	HCPCS	981	RC		both	276.5	235.03	Medicare A ID JF	Default	Other	39.09		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	39.09	268.2
ARTHOCENTESIS INTERNEDIATE JOINT	20605	HCPCS	981	RC		both	276.5	235.03	Medicare B ID JF	Default	Fee Schedule	50.92		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		39.09	268.2
ARTHOCENTESIS INTERNEDIATE JOINT	20605	HCPCS	981	RC		both	276.5	235.03	Regence Group Administrators	Default	Fee Schedule	268.2				39.09	268.2
ARTHOCENTESIS INTERNEDIATE JOINT	20605	HCPCS	981	RC		both	276.5	235.03	SelectHealth	Default	Percent of Total Billed Charges	262.68				39.09	268.2
ARTHOCENTESIS LARGE JOINT	20610	HCPCS	981	RC		both	335	284.75	Blue Cross of ID	Default	Percent of Total Billed Charges	324.95				47.83	324.95
ARTHOCENTESIS LARGE JOINT	20610	HCPCS	981	RC		both	335	284.75	Medicaid Idaho	Default	Fee Schedule	154.1				47.83	324.95
ARTHOCENTESIS LARGE JOINT	20610	HCPCS	981	RC		both	335	284.75	Medicare A ID JF	Default	Other	47.83		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	47.83	324.95
ARTHOCENTESIS LARGE JOINT	20610	HCPCS	981	RC		both	335	284.75	Medicare B ID JF	Default	Fee Schedule	59.73		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		47.83	324.95
ARTHOCENTESIS LARGE JOINT	20610	HCPCS	981	RC		both	335	284.75	Regence Group Administrators	Default	Fee Schedule	324.95				47.83	324.95
ARTHOCENTESIS LARGE JOINT	20610	HCPCS	981	RC		both	335	284.75	SelectHealth	Default	Percent of Total Billed Charges	318.25				47.83	324.95
MANIP/TREATMENT NASAL BONE FRACTURE WO/S	21315	HCPCS	981	RC		both	914.5	777.33	Blue Cross of ID	Default	Percent of Total Billed Charges	887.06				62.86	887.06
MANIP/TREATMENT NASAL BONE FRACTURE WO/S	21315	HCPCS	981	RC		both	914.5	777.33	Medicaid Idaho	Default	Fee Schedule	420.67				62.86	887.06
MANIP/TREATMENT NASAL BONE FRACTURE WO/S	21315	HCPCS	981	RC		both	914.5	777.33	Medicare A ID JF	Default	Other	62.86		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	62.86	887.06
MANIP/TREATMENT NASAL BONE FRACTURE WO/S	21315	HCPCS	981	RC		both	914.5	777.33	Medicare B ID JF	Default	Fee Schedule	139.59		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		62.86	887.06
MANIP/TREATMENT NASAL BONE FRACTURE WO/S	21315	HCPCS	981	RC		both	914.5	777.33	Regence Group Administrators	Default	Fee Schedule	887.06				62.86	887.06
MANIP/TREATMENT NASAL BONE FRACTURE WO/S	21315	HCPCS	981	RC		both	914.5	777.33	SelectHealth	Default	Percent of Total Billed Charges	868.78				62.86	887.06
CLSD TX SEPTAL & NOSE FX WO STABILIZATIO	21337	HCPCS	981	RC		both	1135.5	965.18	Blue Cross of ID	Default	Percent of Total Billed Charges	1101.44				320.74	1101.44
CLSD TX SEPTAL & NOSE FX WO STABILIZATIO	21337	HCPCS	981	RC		both	1135.5	965.18	Medicaid Idaho	Default	Fee Schedule	522.33				320.74	1101.44
CLSD TX SEPTAL & NOSE FX WO STABILIZATIO	21337	HCPCS	981	RC		both	1135.5	965.18	Medicare A ID JF	Default	Other	320.74		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	320.74	1101.44
CLSD TX SEPTAL & NOSE FX WO STABILIZATIO	21337	HCPCS	981	RC		both	1135.5	965.18	Medicare B ID JF	Default	Fee Schedule	384.08		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		320.74	1101.44
CLSD TX SEPTAL & NOSE FX WO STABILIZATIO	21337	HCPCS	981	RC		both	1135.5	965.18	Regence Group Administrators	Default	Fee Schedule	1101.44				320.74	1101.44
CLSD TX SEPTAL & NOSE FX WO STABILIZATIO	21337	HCPCS	981	RC		both	1135.5	965.18	SelectHealth	Default	Percent of Total Billed Charges	1078.72				320.74	1101.44
"EXCISION, TUM, SUBCUTANEOUS, < 3CM"	22902	HCPCS	981	RC		both	1073.5	912.48	Blue Cross of ID	Default	Percent of Total Billed Charges	1041.3				350.58	1041.3
"EXCISION, TUM, SUBCUTANEOUS, < 3CM"	22902	HCPCS	981	RC		both	1073.5	912.48	Medicaid Idaho	Default	Fee Schedule	493.81				350.58	1041.3
"EXCISION, TUM, SUBCUTANEOUS, < 3CM"	22902	HCPCS	981	RC		both	1073.5	912.48	Medicare A ID JF	Default	Other	350.58		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	350.58	1041.3
"EXCISION, TUM, SUBCUTANEOUS, < 3CM"	22902	HCPCS	981	RC		both	1073.5	912.48	Medicare B ID JF	Default	Fee Schedule	429.38		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		350.58	1041.3
"EXCISION, TUM, SUBCUTANEOUS, < 3CM"	22902	HCPCS	981	RC		both	1073.5	912.48	Regence Group Administrators	Default	Fee Schedule	1041.3				350.58	1041.3
"EXCISION, TUM, SUBCUTANEOUS, < 3CM"	22902	HCPCS	981	RC		both	1073.5	912.48	SelectHealth	Default	Percent of Total Billed Charges	1019.82				350.58	1041.3
RED FX-HUMERAL	23605	HCPCS	981	RC		both	1554	1320.9	Blue Cross of ID	Default	Percent of Total Billed Charges	1507.38				441.76	1507.38
RED FX-HUMERAL	23605	HCPCS	981	RC		both	1554	1320.9	Medicaid Idaho	Default	Fee Schedule	714.84				441.76	1507.38
RED FX-HUMERAL	23605	HCPCS	981	RC		both	1554	1320.9	Medicare A ID JF	Default	Other	460.76		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	441.76	1507.38
RED FX-HUMERAL	23605	HCPCS	981	RC		both	1554	1320.9	Medicare B ID JF	Default	Fee Schedule	441.76		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		441.76	1507.38
RED FX-HUMERAL	23605	HCPCS	981	RC		both	1554	1320.9	Regence Group Administrators	Default	Fee Schedule	1507.38				441.76	1507.38
RED FX-HUMERAL	23605	HCPCS	981	RC		both	1554	1320.9	SelectHealth	Default	Percent of Total Billed Charges	1476.3				441.76	1507.38
RED DISLOC SHOULDER	23650	HCPCS	981	RC		both	969	823.65	Blue Cross of ID	Default	Percent of Total Billed Charges	939.93				314.89	939.93
RED DISLOC SHOULDER	23650	HCPCS	981	RC		both	969	823.65	Medicaid Idaho	Default	Fee Schedule	445.74				314.89	939.93
RED DISLOC SHOULDER	23650	HCPCS	981	RC		both	969	823.65	Medicare A ID JF	Default	Other	326.67		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	314.89	939.93
RED DISLOC SHOULDER	23650	HCPCS	981	RC		both	969	823.65	Medicare B ID JF	Default	Fee Schedule	314.89		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		314.89	939.93
RED DISLOC SHOULDER	23650	HCPCS	981	RC		both	969	823.65	Regence Group Administrators	Default	Fee Schedule	939.93				314.89	939.93
RED DISLOC SHOULDER	23650	HCPCS	981	RC		both	969	823.65	SelectHealth	Default	Percent of Total Billed Charges	920.55				314.89	939.93
CLOSE SHOULDER DIS W MANIP W ANES	23655	HCPCS	981	RC		both	1169	993.65	Blue Cross of ID	Default	Percent of Total Billed Charges	1133.93				380.98	1133.93
CLOSE SHOULDER DIS W MANIP W ANES	23655	HCPCS	981	RC		both	1169	993.65	Medicaid Idaho	Default	Fee Schedule	537.74				380.98	1133.93
CLOSE SHOULDER DIS W MANIP W ANES	23655	HCPCS	981	RC		both	1169	993.65	Medicare A ID JF	Default	Other	438.13		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	380.98	1133.93
CLOSE SHOULDER DIS W MANIP W ANES	23655	HCPCS	981	RC		both	1169	993.65	Medicare B ID JF	Default	Fee Schedule	380.98		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		380.98	1133.93
CLOSE SHOULDER DIS W MANIP W ANES	23655	HCPCS	981	RC		both	1169	993.65	Regence Group Administrators	Default	Fee Schedule	1133.93				380.98	1133.93
CLOSE SHOULDER DIS W MANIP W ANES	23655	HCPCS	981	RC		both	1169	993.65	SelectHealth	Default	Percent of Total Billed Charges	1110.55				380.98	1133.93
RED FX OPEN HUMERUS	24515	HCPCS	981	RC		both	2406.5	2045.53	Blue Cross of ID	Default	Percent of Total Billed Charges	2334.3				808.42	2334.3
RED FX OPEN HUMERUS	24515	HCPCS	981	RC		both	2406.5	2045.53	Medicaid Idaho	Default	Fee Schedule	1106.99				808.42	2334.3
RED FX OPEN HUMERUS	24515	HCPCS	981	RC		both	2406.5	2045.53	Medicare A ID JF	Default	Other	929.68		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	808.42	2334.3
RED FX OPEN HUMERUS	24515	HCPCS	981	RC		both	2406.5	2045.53	Medicare B ID JF	Default	Fee Schedule	808.42		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		808.42	2334.3
RED FX OPEN HUMERUS	24515	HCPCS	981	RC		both	2406.5	2045.53	Regence Group Administrators	Default	Fee Schedule	2334.3				808.42	2334.3
RED FX OPEN HUMERUS	24515	HCPCS	981	RC		both	2406.5	2045.53	SelectHealth	Default	Percent of Total Billed Charges	2286.18				808.42	2334.3
TX CLOS.ELBOW DISLOCATION;W/ANESTH	24605	HCPCS	981	RC		both	1405	1194.25	Blue Cross of ID	Default	Percent of Total Billed Charges	1362.85				445.53	1362.85
TX CLOS.ELBOW DISLOCATION;W/ANESTH	24605	HCPCS	981	RC		both	1405	1194.25	Medicaid Idaho	Default	Fee Schedule	646.3				445.53	1362.85
TX CLOS.ELBOW DISLOCATION;W/ANESTH	24605	HCPCS	981	RC		both	1405	1194.25	Medicare A ID JF	Default	Other	512.36		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	445.53	1362.85
TX CLOS.ELBOW DISLOCATION;W/ANESTH	24605	HCPCS	981	RC		both	1405	1194.25	Medicare B ID JF	Default	Fee Schedule	445.53		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		445.53	1362.85
TX CLOS.ELBOW DISLOCATION;W/ANESTH	24605	HCPCS	981	RC		both	1405	1194.25	Regence Group Administrators	Default	Fee Schedule	1362.85				445.53	1362.85
TX CLOS.ELBOW DISLOCATION;W/ANESTH	24605	HCPCS	981	RC		both	1405	1194.25	SelectHealth	Default	Percent of Total Billed Charges	1334.75				445.53	1362.85
"OPEN TRTMENT OF MONTEGGIA, DISC OF ELBOW"	24635	HCPCS	981	RC		both	1940.5	1649.43	Blue Cross of ID	Default	Percent of Total Billed Charges	1882.28				624	1882.28
"OPEN TRTMENT OF MONTEGGIA, DISC OF ELBOW"	24635	HCPCS	981	RC		both	1940.5	1649.43	Medicaid Idaho	Default	Fee Schedule	892.63				624	1882.28
"OPEN TRTMENT OF MONTEGGIA, DISC OF ELBOW"	24635	HCPCS	981	RC		both	1940.5	1649.43	Medicare A ID JF	Default	Other	717.6		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	624	1882.28
"OPEN TRTMENT OF MONTEGGIA, DISC OF ELBOW"	24635	HCPCS	981	RC		both	1940.5	1649.43	Medicare B ID JF	Default	Fee Schedule	624		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		624	1882.28
"OPEN TRTMENT OF MONTEGGIA, DISC OF ELBOW"	24635	HCPCS	981	RC		both	1940.5	1649.43	Regence Group Administrators	Default	Fee Schedule	1882.28				624	1882.28
"OPEN TRTMENT OF MONTEGGIA, DISC OF ELBOW"	24635	HCPCS	981	RC		both	1940.5	1649.43	SelectHealth	Default	Percent of Total Billed Charges	1843.48				624	1882.28
CLOSE DIST RAD W/WO ULNA W MANIP	25605	HCPCS	981	RC		both	1602	1361.7	Blue Cross of ID	Default	Percent of Total Billed Charges	1553.94				506.97	1553.94
CLOSE DIST RAD W/WO ULNA W MANIP	25605	HCPCS	981	RC		both	1602	1361.7	Medicaid Idaho	Default	Fee Schedule	736.92				506.97	1553.94
CLOSE DIST RAD W/WO ULNA W MANIP	25605	HCPCS	981	RC		both	1602	1361.7	Medicare A ID JF	Default	Other	549.99		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of the Medicare Professional Fee Schedule rate.  Reimbursement is subject to Medicare Sequestration.	"Method II reimbursement for outpatient CAH services is 101 percent of the reasonable cost less applicable Part B deductible and coinsurance amounts. Under Method II, payment for professional medical services furnished in a CAH to CAH outpatients is reimbursed at 115% of what would otherwise be paid under the fee schedule."	506.97	1553.94
CLOSE DIST RAD W/WO ULNA W MANIP	25605	HCPCS	981	RC		both	1602	1361.7	Medicare B ID JF	Default	Fee Schedule	506.97		"""Reimbursement is based on the Medicare Professional Services Fee Schedule. Reimbursement is subject to modifier adjustments, multiple procedure reductions and mid-level provider adjustments when applicable.  Reimbursement is subject to Medicare Sequestration. """		506.97	1553.94
CLOSE DIST RAD W/WO ULNA W MANIP	25605	HCPCS	981	RC		both	1602	1361.7	Regence Group Administrators	Default	Fee Schedule	1553.94				506.97	1553.94
CLOSE DIST RAD W/WO ULNA W MANIP	25605	HCPCS	981	RC		both	1602	1361.7	SelectHealth	Default	Percent of Total Billed Charges	1521.9				506.97	1553.94
PERCUTANEOUS SKELETAL FIXATION OD DISTAL	25606	HCPCS	981	RC		both	1534	1303.9	Blue Cross of ID	Default	Percent of Total Billed Charges	1487.98				619.46	1487.98
PERCUTANEOUS SKELETAL FIXATION OD DISTAL	25606	HCPCS	981	RC		both	1534	1303.9	Medicaid Idaho	Default	Fee Schedule	705.64				619.46	1487.98
PERCUTANEOUS SKELETAL FIXATION OD DISTAL	25606	HCPCS	981	RC		both	1534	1303.9	Medicare A ID JF	Default	Other	712.38		Reimbursement  is based on the facility specific Medicare Interim Rate letter. Professional services billed on the hospital claim are paid at  115% of