1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 1 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ G0101 34.93 33.18 38.16 G0270 22.88 21.74 25.00 G0102 19.04 18.09 20.80 # G0270 21.01 19.96 22.95 # G0102 8.55 8.12 9.34 G0271 12.93 12.28 14.12 G0104 127.02 120.67 138.77 G0275 14.05 13.35 15.35 # G0104 58.44 55.52 63.85 G0278 14.05 13.35 15.35 G0105 371.92 353.32 406.32 G0281 11.53 10.95 12.59 # G0105 204.79 194.55 223.73 G0283 11.53 10.95 12.59 G0105 53 127.02 120.67 138.77 G0288 130.41 123.89 142.47 # G0105 53 58.44 55.52 63.85 G0289 82.82 78.68 90.48 G0106 201.17 191.11 219.78 G0329 7.95 7.55 8.68 G0106 TC 150.93 143.38 164.89 G0339 3,958.14 3,760.23 4,324.26 G0106 26 50.24 47.73 54.89 G0340 2,687.41 2,553.04 2,936.00 G0108 23.77 22.58 25.97 G0341 403.27 383.11 440.58 G0109 13.28 12.62 14.51 G0342 651.35 618.78 711.60 G0117 44.50 42.28 48.62 G0343 1,082.80 1,028.66 1,182.96 G0118 30.28 28.77 33.09 G0364 12.43 11.81 13.58 G0120 201.17 191.11 219.78 # G0364 9.06 8.61 9.90 G0120 TC 150.93 143.38 164.89 C G0365 167.07 158.72 182.53 G0120 26 50.24 47.73 54.89 C G0365 TC 155.10 147.35 169.45 G0121 371.92 353.32 406.32 G0365 26 11.97 11.37 13.08 # G0121 204.79 194.55 223.73 G0372 11.17 10.61 12.20 G0121 53 127.02 120.67 138.77 # G0372 8.17 7.76 8.92 # G0121 53 58.44 55.52 63.85 G0389 112.31 106.69 122.69 G0124 27.10 25.75 29.61 G0389 TC 82.28 78.17 89.90 G0127 19.04 18.09 20.80 G0389 26 30.04 28.54 32.82 # G0127 8.17 7.76 8.92 G0392 2,215.03 2,104.28 2,419.92 G0128 8.30 7.89 9.07 # G0392 440.68 418.65 481.45 G0130 32.17 30.56 35.14 G0393 1,675.98 1,592.18 1,831.01 G0130 TC 21.82 20.73 23.84 # G0393 311.21 295.65 340.00 G0130 26 10.35 9.83 11.30 G0396 31.10 29.55 33.98 G0141 27.10 25.75 29.61 # G0396 29.61 28.13 32.35 G0166 155.58 147.80 169.97 G0397 60.50 57.48 66.10 G0168 77.44 73.57 84.61 # G0397 59.00 56.05 64.46 # G0168 24.60 23.37 26.88 G0398 293.59 278.91 320.75 G0179 39.42 37.45 43.07 G0398 TC 209.18 198.72 228.53 G0180 52.02 49.42 56.83 G0398 26 84.42 80.20 92.23 G0181 100.29 95.28 109.57 G0399 211.55 200.97 231.12 G0182 102.53 97.40 112.01 G0399 TC 132.90 126.26 145.20 G0202 131.84 125.25 144.04 G0399 26 78.66 74.73 85.94 G0202 TC 97.10 92.25 106.09 G0400 190.39 180.87 208.00 G0202 26 34.74 33.00 37.95 G0400 TC 119.60 113.62 130.66 G0204 155.00 147.25 169.34 G0400 26 70.79 67.25 77.34 G0204 TC 112.09 106.49 122.46 G0402 92.34 87.72 100.88 G0204 26 42.91 40.76 46.87 G0403 20.87 19.83 22.80 G0206 123.05 116.90 134.44 G0404 13.82 13.13 15.10 G0206 TC 88.31 83.89 96.47 G0405 8.17 7.76 8.92 G0206 26 34.74 33.00 37.95 G0406 36.90 35.06 40.32 G0237 10.45 9.93 11.42 G0407 66.54 63.21 72.69 G0238 11.20 10.64 12.24 G0408 95.24 90.48 104.05 G0239 11.58 11.00 12.65 G0409 8.79 8.35 9.60 G0245 63.51 60.33 69.38 G0412 661.33 628.26 722.50 # G0245 44.40 42.18 48.51 G0413 968.44 920.02 1,058.02 G0246 37.17 35.31 40.61 G0414 917.58 871.70 1,002.46 # G0246 22.56 21.43 24.64 G0415 1,250.71 1,188.17 1,366.40 G0247 41.60 39.52 45.45 G0416 643.57 611.39 703.10 # G0247 24.74 23.50 27.03 G0416 TC 459.92 436.92 502.46 G0248 154.18 146.47 168.44 G0416 26 183.65 174.47 200.64 G0249 130.95 124.40 143.06 G0417 1,250.53 1,188.00 1,366.20 G0250 9.66 9.18 10.56 G0417 TC 898.49 853.57 981.61 G0268 47.07 44.72 51.43 G0417 26 352.05 334.45 384.62 # G0268 30.58 29.05 33.41 G0418 2,146.23 2,038.92 2,344.76 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 2 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ G0418 TC 1,534.83 1,458.09 1,676.80 # 10040 79.35 75.38 86.69 G0418 26 611.40 580.83 667.95 10060 97.76 92.87 106.80 G0419 2,547.98 2,420.58 2,783.67 # 10060 83.89 79.70 91.66 G0419 TC 1,841.69 1,749.61 2,012.05 10061 166.19 157.88 181.56 G0419 26 706.29 670.98 771.63 # 10061 147.82 140.43 161.49 G9041 22.78 21.64 24.89 10080 147.43 140.06 161.07 G9042 7.52 7.14 8.21 # 10080 85.97 81.67 93.92 G9043 7.15 6.79 7.81 10081 229.49 218.02 250.72 G9044 6.77 6.43 7.39 # 10081 148.54 141.11 162.28 M0064 41.24 39.18 45.06 10120 120.56 114.53 131.71 # M0064 16.51 15.68 18.03 # 10120 81.96 77.86 89.54 P3001 27.10 25.75 29.61 10121 232.90 221.26 254.45 Q0035 19.00 18.05 20.76 # 10121 166.19 157.88 181.56 Q0035 TC 10.83 10.29 11.83 10140 137.76 130.87 150.50 Q0035 26 8.17 7.76 8.92 # 10140 107.03 101.68 116.93 Q0091 40.66 38.63 44.42 10160 112.29 106.68 122.68 # Q0091 17.80 16.91 19.45 # 10160 86.43 82.11 94.43 Q0092 16.65 15.82 18.19 10180 206.49 196.17 225.60 R0070 117.10 111.25 127.94 # 10180 157.40 149.53 171.96 R0075 117.10 111.25 127.94 11000 48.29 45.88 52.76 0067T 608.75 578.31 665.06 # 11000 29.55 28.07 32.28 C 0067T TC 193.03 183.38 210.89 11001 20.11 19.10 21.97 0067T 26 128.18 121.77 140.04 # 11001 14.86 14.12 16.24 0073T 534.29 507.58 583.72 11004 534.09 507.39 583.50 0075T 1,120.15 1,064.14 1,223.76 11005 695.59 660.81 759.93 0075T 26 914.45 868.73 999.04 11006 656.43 623.61 717.15 0076T 369.65 351.17 403.85 11008 248.96 236.51 271.99 0076T 26 91.44 86.87 99.90 11010 418.81 397.87 457.55 0078T 1,275.78 1,211.99 1,393.79 # 11010 255.42 242.65 279.05 0079T 1,176.48 1,117.66 1,285.31 11011 465.93 442.63 509.02 0080T 227.97 216.57 249.06 # 11011 273.32 259.65 298.60 0081T 227.97 216.57 249.06 11012 634.72 602.98 693.43 0145T 607.41 577.04 663.60 # 11012 396.01 376.21 432.64 C 0145T TC 280.68 266.65 306.65 11040 42.27 40.16 46.18 0145T 26 102.11 97.00 111.55 # 11040 25.40 24.13 27.75 0146T 607.41 577.04 663.60 11041 49.16 46.70 53.71 C 0146T TC 280.68 266.65 306.65 # 11041 31.55 29.97 34.47 0146T 26 102.11 97.00 111.55 11042 66.62 63.29 72.78 0147T 607.41 577.04 663.60 # 11042 42.26 40.15 46.17 C 0147T TC 280.68 266.65 306.65 11043 243.88 231.69 266.44 0147T 26 102.11 97.00 111.55 # 11043 212.03 201.43 231.64 0148T 607.41 577.04 663.60 11044 333.40 316.73 364.24 C 0148T TC 280.68 266.65 306.65 # 11044 292.18 277.57 319.21 0148T 26 102.11 97.00 111.55 11055 43.70 41.52 47.75 0149T 607.41 577.04 663.60 # 11055 21.21 20.15 23.17 C 0149T TC 280.68 266.65 306.65 11056 53.15 50.49 58.06 0149T 26 102.11 97.00 111.55 # 11056 29.91 28.41 32.67 0150T 607.41 577.04 663.60 11057 63.88 60.69 69.79 C 0150T TC 280.68 266.65 306.65 # 11057 38.78 36.84 42.37 0150T 26 102.11 97.00 111.55 11100 93.79 89.10 102.47 0151T 197.63 187.75 215.91 # 11100 44.70 42.47 48.84 C 0151T TC 104.26 99.05 113.91 11101 30.11 28.60 32.89 0151T 26 66.99 63.64 73.19 # 11101 22.99 21.84 25.12 0171T 723.72 687.53 790.66 11200 73.38 69.71 80.17 0172T 361.87 343.78 395.35 # 11200 61.76 58.67 67.47 0177T 1,232.97 1,171.32 1,347.02 11201 16.79 15.95 18.34 10021 128.04 121.64 139.89 # 11201 15.29 14.53 16.71 # 10021 63.58 60.40 69.46 11300 61.24 58.18 66.91 10022 131.83 125.24 144.03 # 11300 27.14 25.78 29.65 # 10022 63.25 60.09 69.10 11301 83.79 79.60 91.54 10040 90.97 86.42 99.38 # 11301 46.31 43.99 50.59 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 3 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 11302 100.16 95.15 109.42 # 11462 199.08 189.13 217.50 # 11302 57.44 54.57 62.76 11463 415.46 394.69 453.89 11303 117.46 111.59 128.33 # 11463 277.56 263.68 303.23 # 11303 67.25 63.89 73.47 11470 339.15 322.19 370.52 11305 62.43 59.31 68.21 # 11470 234.97 223.22 256.70 # 11305 33.95 32.25 37.09 11471 425.22 403.96 464.55 11306 86.34 82.02 94.32 # 11471 294.44 279.72 321.68 # 11306 51.86 49.27 56.66 11600 159.45 151.48 174.20 11307 102.24 97.13 111.70 # 11600 100.25 95.24 109.53 # 11307 61.39 58.32 67.07 11601 197.02 187.17 215.25 11308 114.10 108.40 124.66 # 11601 129.94 123.44 141.96 # 11308 73.26 69.60 80.04 11602 216.60 205.77 236.64 11310 76.09 72.29 83.13 # 11602 143.15 135.99 156.39 # 11310 39.36 37.39 43.00 11603 245.34 233.07 268.03 11311 96.41 91.59 105.33 # 11603 169.65 161.17 185.35 # 11311 57.81 54.92 63.16 11604 270.62 257.09 295.65 11312 111.36 105.79 121.66 # 11604 185.94 176.64 203.14 # 11312 66.39 63.07 72.53 11606 378.99 360.04 414.05 11313 138.79 131.85 151.63 # 11606 274.06 260.36 299.41 # 11313 88.57 84.14 96.76 11620 163.02 154.87 178.10 11400 103.95 98.75 113.56 # 11620 101.94 96.84 111.37 # 11400 67.23 63.87 73.45 11621 198.88 188.94 217.28 11401 127.32 120.95 139.09 # 11621 131.42 124.85 143.58 # 11401 89.09 84.64 97.34 11622 224.98 213.73 245.79 11402 141.82 134.73 154.94 # 11622 151.53 143.95 165.54 # 11402 98.35 93.43 107.44 11623 261.72 248.63 285.92 11403 162.55 154.42 177.58 # 11623 186.02 176.72 203.23 # 11403 125.07 118.82 136.64 11624 293.64 278.96 320.80 11404 184.94 175.69 202.04 # 11624 210.83 200.29 230.33 # 11404 138.85 131.91 151.70 11626 355.96 338.16 388.88 11406 259.39 246.42 283.38 # 11626 262.65 249.52 286.95 # 11406 206.55 196.22 225.65 11640 170.43 161.91 186.20 11420 104.64 99.41 114.32 # 11640 107.48 102.11 117.43 # 11420 72.42 68.80 79.12 11641 209.16 198.70 228.51 11421 135.42 128.65 147.95 # 11641 140.21 133.20 153.18 # 11421 97.57 92.69 106.59 11642 240.88 228.84 263.17 11422 150.99 143.44 164.96 # 11642 165.18 156.92 180.46 # 11422 118.01 112.11 128.93 11643 282.14 268.03 308.23 11423 175.48 166.71 191.72 # 11643 205.69 195.41 224.72 # 11423 137.25 130.39 149.95 11644 347.51 330.13 379.65 11424 201.95 191.85 220.63 # 11644 255.70 242.92 279.36 # 11424 157.73 149.84 172.32 11646 455.60 432.82 497.74 11426 287.57 273.19 314.17 # 11646 358.55 340.62 391.71 # 11426 239.60 227.62 261.76 11719 19.21 18.25 20.99 11440 114.94 109.19 125.57 # 11719 8.34 7.92 9.11 # 11440 87.59 83.21 95.69 11720 27.95 26.55 30.53 11441 145.08 137.83 158.50 # 11720 15.58 14.80 17.02 # 11441 114.35 108.63 124.92 11721 39.75 37.76 43.42 11442 163.23 155.07 178.33 # 11721 26.64 25.31 29.11 # 11442 127.25 120.89 139.02 11730 88.10 83.70 96.26 11443 195.28 185.52 213.35 # 11730 54.00 51.30 59.00 # 11443 156.68 148.85 171.18 11732 40.84 38.80 44.62 11444 245.63 233.35 268.35 # 11732 28.09 26.69 30.69 # 11444 200.29 190.28 218.82 11740 40.62 38.59 44.38 11446 333.25 316.59 364.08 # 11740 29.00 27.55 31.68 # 11446 282.66 268.53 308.81 11750 191.40 181.83 209.10 11450 309.65 294.17 338.30 # 11750 158.43 150.51 173.09 # 11450 206.60 196.27 225.71 11752 271.87 258.28 297.02 11451 403.68 383.50 441.03 # 11752 237.02 225.17 258.95 # 11451 271.77 258.18 296.91 11755 119.65 113.67 130.72 11462 306.26 290.95 334.59 # 11755 78.06 74.16 85.28 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 4 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 11760 180.37 171.35 197.05 # 12014 130.75 124.21 142.84 # 11760 118.17 112.26 129.10 12015 226.66 215.33 247.63 11762 239.86 227.87 262.05 # 12015 163.70 155.52 178.85 # 11762 180.28 171.27 196.96 12016 270.43 256.91 295.45 11765 116.13 110.32 126.87 # 12016 199.61 189.63 218.07 # 11765 61.42 58.35 67.10 12017 237.27 225.41 259.22 11770 229.64 218.16 250.88 12018 294.04 279.34 321.24 # 11770 157.69 149.81 172.28 12020 238.12 226.21 260.14 11771 469.34 445.87 512.75 # 12020 167.67 159.29 183.18 # 11771 365.91 347.61 399.75 12021 140.03 133.03 152.98 11772 569.76 541.27 622.46 # 12021 121.67 115.59 132.93 # 11772 479.82 455.83 524.20 12031 211.88 201.29 231.48 11900 50.94 48.39 55.65 # 12031 141.43 134.36 154.51 # 11900 28.46 27.04 31.10 12032 274.22 260.51 299.59 11901 64.20 60.99 70.14 # 12032 174.91 166.16 191.08 # 11901 44.34 42.12 48.44 12034 268.34 254.92 293.16 11920 162.87 154.73 177.94 # 12034 181.03 171.98 197.78 # 11920 104.04 98.84 113.67 12035 326.93 310.58 357.17 11921 185.36 176.09 202.50 # 12035 211.51 200.93 231.07 # 11921 122.41 116.29 133.73 12036 356.83 338.99 389.84 11922 54.81 52.07 59.88 # 12036 242.91 230.76 265.37 # 11922 27.46 26.09 30.00 12037 402.01 381.91 439.20 11950 68.02 64.62 74.31 # 12037 282.84 268.70 309.01 # 11950 46.28 43.97 50.57 12041 221.65 210.57 242.16 11951 90.47 85.95 98.84 # 12041 151.20 143.64 165.19 # 11951 64.24 61.03 70.18 12042 259.01 246.06 282.97 11952 127.32 120.95 139.09 # 12042 177.32 168.45 193.72 # 11952 92.85 88.21 101.44 12044 298.34 283.42 325.93 11954 145.09 137.84 158.52 # 12044 189.67 180.19 207.22 # 11954 103.87 98.68 113.48 12045 329.21 312.75 359.66 11960 818.39 777.47 894.09 # 12045 219.42 208.45 239.72 11970 534.06 507.36 583.46 12046 389.73 370.24 425.78 11971 409.27 388.81 447.13 # 12046 258.20 245.29 282.08 # 11971 268.00 254.60 292.79 12047 417.94 397.04 456.60 11976 134.77 128.03 147.23 # 12047 282.66 268.53 308.81 # 11976 88.31 83.89 96.47 12051 238.53 226.60 260.59 11980 95.27 90.51 104.09 # 12051 162.09 153.99 177.09 # 11980 74.66 70.93 81.57 12052 270.94 257.39 296.00 11981 124.70 118.47 136.24 # 12052 191.12 181.56 208.79 # 11981 78.99 75.04 86.30 12053 297.33 282.46 324.83 11982 143.10 135.95 156.34 # 12053 192.78 183.14 210.61 # 11982 96.26 91.45 105.17 12054 313.77 298.08 342.79 11983 220.66 209.63 241.07 # 12054 203.97 193.77 222.84 # 11983 176.81 167.97 193.17 12055 376.73 357.89 411.57 12001 130.86 124.32 142.97 # 12055 247.45 235.08 270.34 # 12001 92.26 87.65 100.80 12056 444.26 422.05 485.36 12002 139.21 132.25 152.09 # 12056 302.23 287.12 330.19 # 12002 102.49 97.37 111.98 12057 497.08 472.23 543.06 12004 164.08 155.88 179.26 # 12057 347.19 329.83 379.30 # 12004 120.23 114.22 131.35 13100 282.46 268.34 308.59 12005 204.30 194.09 223.20 # 13100 212.01 201.41 231.62 # 12005 149.59 142.11 163.43 13101 357.42 339.55 390.48 12006 253.23 240.57 276.66 # 13101 257.74 244.85 281.58 # 12006 188.77 179.33 206.23 13102 95.98 91.18 104.86 12007 286.49 272.17 313.00 # 13102 67.87 64.48 74.15 # 12007 215.66 204.88 235.61 13120 293.45 278.78 320.60 12011 139.19 132.23 152.06 # 13120 221.50 210.43 241.99 # 12011 95.34 90.57 104.16 13121 396.00 376.20 432.63 12013 153.44 145.77 167.64 # 13121 292.95 278.30 320.05 # 12013 108.84 103.40 118.91 13122 107.27 101.91 117.20 12014 180.59 171.56 197.29 # 13122 77.67 73.79 84.86 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 5 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 13131 323.88 307.69 353.84 # 15121 155.51 147.73 169.89 # 13131 250.06 237.56 273.19 15130 596.69 566.86 651.89 13132 518.59 492.66 566.56 # 15130 499.26 474.30 545.45 # 13132 422.29 401.18 461.36 15131 88.70 84.27 96.91 13133 151.69 144.11 165.73 # 15131 79.71 75.72 87.08 # 13133 121.33 115.26 132.55 15135 766.60 728.27 837.51 13150 321.81 305.72 351.58 # 15135 685.29 651.03 748.68 # 13150 247.99 235.59 270.93 15136 81.42 77.35 88.95 13151 367.25 348.89 401.22 # 15136 75.42 71.65 82.40 # 13151 289.31 274.84 316.07 15150 620.10 589.10 677.47 13152 505.88 480.59 552.68 # 15150 568.39 539.97 620.97 # 13152 388.59 369.16 424.53 15151 114.65 108.92 125.26 13153 166.28 157.97 181.67 # 15151 105.28 100.02 115.02 # 13153 131.06 124.51 143.19 15152 149.59 142.11 163.43 13160 722.12 686.01 788.91 # 15152 139.09 132.14 151.96 14000 548.98 521.53 599.76 15155 653.52 620.84 713.97 # 14000 448.18 425.77 489.64 # 15155 610.43 579.91 666.90 14001 712.09 676.49 777.96 15156 159.52 151.54 174.27 # 14001 593.67 563.99 648.59 # 15156 150.90 143.36 164.86 14020 618.35 587.43 675.54 15157 176.15 167.34 192.44 # 14020 513.42 487.75 560.91 # 15157 163.79 155.60 178.94 14021 782.17 743.06 854.52 15170 379.22 360.26 414.30 # 14021 662.63 629.50 723.93 # 15170 326.76 310.42 356.98 14040 686.47 652.15 749.97 15171 84.18 79.97 91.97 # 14040 583.79 554.60 637.79 # 15171 80.05 76.05 87.46 14041 854.22 811.51 933.24 15175 480.58 456.55 525.03 # 14041 720.82 684.78 787.50 # 15175 431.12 409.56 470.99 14060 696.70 661.87 761.15 15176 134.79 128.05 147.26 # 14060 615.76 584.97 672.72 # 15176 126.92 120.57 138.66 14061 915.68 869.90 1,000.39 15200 713.83 678.14 779.86 # 14061 769.16 730.70 840.31 # 15200 585.30 556.04 639.45 14300 985.47 936.20 1,076.63 15201 132.47 125.85 144.73 # 14300 856.57 813.74 935.80 # 15201 72.13 68.52 78.80 14350 672.26 638.65 734.45 15220 681.45 647.38 744.49 15002 296.45 281.63 323.87 # 15220 555.54 527.76 606.92 # 15002 204.64 194.41 223.57 15221 123.53 117.35 134.95 15003 64.41 61.19 70.37 # 15221 66.20 62.89 72.32 # 15003 41.18 39.12 44.99 15240 817.59 776.71 893.22 15004 359.13 341.17 392.35 # 15240 711.17 675.61 776.95 # 15004 255.71 242.92 279.36 15241 164.60 156.37 179.83 15005 107.46 102.09 117.40 # 15241 103.52 98.34 113.09 # 15005 81.61 77.53 89.16 15260 888.46 844.04 970.65 15040 227.90 216.51 248.99 # 15260 772.67 734.04 844.15 # 15040 115.48 109.71 126.17 15261 192.23 182.62 210.01 15050 480.48 456.46 524.93 # 15261 131.14 124.58 143.27 # 15050 392.42 372.80 428.72 15300 304.41 289.19 332.57 15100 766.46 728.14 837.36 # 15300 259.81 246.82 283.84 # 15100 637.55 605.67 696.52 15301 56.76 53.92 62.01 15101 169.83 161.34 185.54 # 15301 52.26 49.65 57.10 # 15101 101.63 96.55 111.03 15320 342.76 325.62 374.46 15110 753.74 716.05 823.46 # 15320 293.67 278.99 320.84 # 15110 654.44 621.72 714.98 15321 84.58 80.35 92.40 15111 108.90 103.46 118.98 # 15321 78.58 74.65 85.85 # 15111 97.29 92.43 106.29 15330 281.73 267.64 307.79 15115 764.13 725.92 834.81 # 15330 236.01 224.21 257.84 # 15115 679.81 645.82 742.69 15331 56.76 53.92 62.01 15116 148.13 140.72 161.83 # 15331 52.64 50.01 57.51 # 15116 134.64 127.91 147.10 15335 295.88 281.09 323.25 15120 833.94 792.24 911.08 # 15335 251.28 238.72 274.53 # 15120 700.54 665.51 765.34 15336 78.89 74.95 86.19 15121 239.07 227.12 261.19 # 15336 72.15 68.54 78.82 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 6 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 15340 282.97 268.82 309.14 15776 400.31 380.29 437.33 # 15340 242.50 230.38 264.94 # 15776 301.38 286.31 329.26 15341 42.27 40.16 46.18 15780 744.18 706.97 813.02 # 15341 25.03 23.78 27.35 # 15780 581.92 552.82 635.74 15360 321.66 305.58 351.42 15781 479.17 455.21 523.49 # 15360 274.07 260.37 299.43 # 15781 385.48 366.21 421.14 15361 63.67 60.49 69.56 15782 508.79 483.35 555.85 # 15361 57.67 54.79 63.01 # 15782 370.89 352.35 405.20 15365 315.39 299.62 344.56 15783 436.64 414.81 477.03 # 15365 272.67 259.04 297.90 # 15783 333.96 317.26 364.85 15366 78.36 74.44 85.61 15786 214.42 203.70 234.26 # 15366 71.99 68.39 78.65 # 15786 124.48 118.26 136.00 15400 351.67 334.09 384.20 15787 44.05 41.85 48.13 # 15400 316.45 300.63 345.72 # 15787 17.07 16.22 18.65 15401 84.12 79.91 91.90 15788 385.24 365.98 420.88 # 15401 51.89 49.30 56.70 # 15788 214.36 203.64 234.19 15420 396.75 376.91 433.45 15789 510.56 485.03 557.78 # 15420 351.04 333.49 383.51 # 15789 385.40 366.13 421.05 15421 102.57 97.44 112.06 15792 379.15 360.19 414.22 # 15421 77.46 73.59 84.63 # 15792 236.38 224.56 258.24 15430 466.57 443.24 509.73 15793 424.99 403.74 464.30 # 15430 449.34 426.87 490.90 # 15793 320.06 304.06 349.67 15570 782.08 742.98 854.43 15819 659.49 626.52 720.50 # 15570 636.31 604.49 695.16 15820 476.26 452.45 520.32 15572 759.23 721.27 829.46 # 15820 429.79 408.30 469.55 # 15572 646.06 613.76 705.82 15821 505.89 480.60 552.69 15574 801.50 761.43 875.64 # 15821 454.93 432.18 497.01 # 15574 683.09 648.94 746.28 15822 373.05 354.40 407.56 15576 714.24 678.53 780.31 # 15822 328.84 312.40 359.26 # 15576 601.45 571.38 657.09 15823 588.24 558.83 642.65 15600 293.30 278.64 320.44 # 15823 539.90 512.91 589.85 # 15600 180.50 171.48 197.20 15830 1,037.95 986.05 1,133.96 15610 293.16 278.50 320.28 15832 793.81 754.12 867.24 # 15610 212.97 202.32 232.67 15833 749.96 712.46 819.33 15620 389.34 369.87 425.35 15834 744.84 707.60 813.74 # 15620 282.54 268.41 308.67 15835 788.11 748.70 861.01 15630 411.56 390.98 449.63 15836 657.47 624.60 718.29 # 15630 309.26 293.80 337.87 15837 685.12 650.86 748.49 15650 458.39 435.47 500.79 # 15837 595.56 565.78 650.65 # 15650 347.85 330.46 380.03 15838 516.94 491.09 564.75 15731 1,009.87 959.38 1,103.29 15839 758.65 720.72 828.83 # 15731 911.69 866.11 996.03 # 15839 645.11 612.85 704.78 15732 1,332.17 1,265.56 1,455.39 15840 907.71 862.32 991.67 # 15732 1,180.78 1,121.74 1,290.00 15841 1,513.53 1,437.85 1,653.53 15734 1,365.47 1,297.20 1,491.78 15842 2,382.53 2,263.40 2,602.91 # 15734 1,207.33 1,146.96 1,319.00 15845 854.51 811.78 933.55 15736 1,209.59 1,149.11 1,321.48 15851 84.10 79.90 91.89 # 15736 1,040.96 988.91 1,137.25 # 15851 41.76 39.67 45.62 15738 1,288.80 1,224.36 1,408.01 15852 43.38 41.21 47.39 # 15738 1,133.29 1,076.63 1,238.12 15860 101.81 96.72 111.23 15740 909.69 864.21 993.84 15920 521.50 495.43 569.74 # 15740 778.54 739.61 850.55 15922 662.05 628.95 723.29 15750 817.42 776.55 893.03 15931 591.78 562.19 646.52 15756 2,139.17 2,032.21 2,337.04 15933 730.37 693.85 797.93 15757 2,122.38 2,016.26 2,318.70 15934 811.96 771.36 887.06 15758 2,121.65 2,015.57 2,317.91 15935 967.89 919.50 1,057.43 15760 752.26 714.65 821.85 15936 787.22 747.86 860.04 # 15760 634.59 602.86 693.29 15937 920.99 874.94 1,006.18 15770 586.05 556.75 640.26 15940 608.68 578.25 664.99 15775 289.03 274.58 315.77 15941 793.26 753.60 866.64 # 15775 210.71 200.17 230.20 15944 780.68 741.65 852.90 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 7 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 15945 867.25 823.89 947.47 # 17280 80.85 76.81 88.33 15946 1,447.07 1,374.72 1,580.93 17281 158.73 150.79 173.41 15950 505.72 480.43 552.49 # 17281 112.64 107.01 123.06 15951 720.77 684.73 787.44 17282 183.93 174.73 200.94 15952 757.17 719.31 827.21 # 17282 130.72 124.18 142.81 15953 843.44 801.27 921.46 17283 221.81 210.72 242.33 15956 1,013.82 963.13 1,107.60 # 17283 163.35 155.18 178.46 15958 1,035.52 983.74 1,131.30 17284 257.69 244.81 281.53 16000 61.54 58.46 67.23 # 17284 194.73 184.99 212.74 # 16000 42.43 40.31 46.36 17286 324.71 308.47 354.74 16020 72.91 69.26 79.65 # 17286 261.01 247.96 285.15 # 16020 51.17 48.61 55.90 17311 626.70 595.37 684.68 16025 130.97 124.42 143.08 # 17311 349.77 332.28 382.12 # 16025 103.99 98.79 113.61 17312 376.38 357.56 411.19 16030 156.96 149.11 171.48 # 17312 186.01 176.71 203.22 # 16030 117.99 112.09 128.90 17313 572.18 543.57 625.11 16035 193.52 183.84 211.42 # 17313 313.99 298.29 343.03 16036 76.92 73.07 84.03 17314 348.82 331.38 381.09 17000 71.20 67.64 77.79 # 17314 172.70 164.07 188.68 # 17000 49.09 46.64 53.64 17315 74.60 70.87 81.50 17003 6.81 6.47 7.44 # 17315 49.12 46.66 53.66 # 17003 4.19 3.98 4.58 17340 43.61 41.43 47.64 17004 158.16 150.25 172.79 # 17340 42.11 40.00 46.00 # 17004 122.56 116.43 133.89 17360 118.89 112.95 129.89 17106 309.53 294.05 338.16 # 17360 90.78 86.24 99.18 # 17106 252.57 239.94 275.93 19000 103.95 98.75 113.56 17107 409.00 388.55 446.83 # 19000 42.87 40.73 46.84 # 17107 332.93 316.28 363.72 19001 25.56 24.28 27.92 17108 523.91 497.71 572.37 # 19001 21.44 20.37 23.43 # 17108 435.85 414.06 476.17 19020 386.34 367.02 422.07 17110 99.19 94.23 108.36 # 19020 253.31 240.64 276.74 # 17110 61.35 58.28 67.02 19030 159.36 151.39 174.10 17111 117.55 111.67 128.42 # 19030 78.04 74.14 85.26 # 17111 76.33 72.51 83.39 19100 126.04 119.74 137.70 17250 67.00 63.65 73.20 # 19100 62.34 59.22 68.10 # 17250 32.90 31.26 35.95 19101 286.42 272.10 312.92 17260 85.55 81.27 93.46 # 19101 190.86 181.32 208.52 # 17260 60.81 57.77 66.44 19102 208.62 198.19 227.92 17261 128.07 121.67 139.92 # 19102 101.82 96.73 111.24 # 17261 82.35 78.23 89.96 19103 528.56 502.13 577.45 17262 155.76 147.97 170.17 # 19103 186.43 177.11 203.68 # 17262 105.17 99.91 114.90 19105 2,057.46 1,954.59 2,247.78 17263 171.75 163.16 187.63 # 19105 186.80 177.46 204.08 # 17263 116.29 110.48 127.05 19110 398.72 378.78 435.60 17264 183.69 174.51 200.69 # 19110 285.18 270.92 311.56 # 17264 124.11 117.90 135.59 19112 374.12 355.41 408.72 17266 208.40 197.98 227.68 # 19112 256.83 243.99 280.59 # 17266 144.33 137.11 157.68 19120 409.03 388.58 446.87 17270 132.73 126.09 145.00 # 19120 348.33 330.91 380.55 # 17270 88.88 84.44 97.11 19125 452.61 429.98 494.48 17271 146.52 139.19 160.07 # 19125 386.29 366.98 422.03 # 17271 100.05 95.05 109.31 19126 143.86 136.67 157.17 17272 167.65 159.27 183.16 19260 1,066.90 1,013.56 1,165.59 # 17272 115.94 110.14 126.66 19271 1,455.79 1,383.00 1,590.45 17273 186.91 177.56 204.19 19272 1,611.06 1,530.51 1,760.09 # 17273 130.70 124.17 142.80 19290 155.27 147.51 169.64 17274 220.96 209.91 241.40 # 19290 64.58 61.35 70.55 # 17274 160.25 152.24 175.08 19291 66.86 63.52 73.05 17276 255.20 242.44 278.81 # 19291 32.01 30.41 34.97 # 17276 192.25 182.64 210.04 19295 88.23 83.82 96.39 17280 124.69 118.46 136.23 19296 3,677.76 3,493.87 4,017.95 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 8 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 19296 186.38 177.06 203.62 20250 337.25 320.39 368.45 19297 83.98 79.78 91.75 20251 373.90 355.21 408.49 19298 1,239.09 1,177.14 1,353.71 20500 106.29 100.98 116.13 # 19298 308.63 293.20 337.18 # 20500 86.80 82.46 94.83 19300 439.25 417.29 479.88 20501 122.13 116.02 133.42 # 19300 339.57 322.59 370.98 # 20501 38.94 36.99 42.54 19301 539.84 512.85 589.78 20520 170.62 162.09 186.40 19302 768.55 730.12 839.64 # 20520 128.28 121.87 140.15 19303 834.77 793.03 911.98 20525 418.76 397.82 457.49 19304 483.75 459.56 528.49 # 20525 223.15 211.99 243.79 19305 961.24 913.18 1,050.16 20526 68.30 64.89 74.62 19306 1,007.46 957.09 1,100.65 # 20526 52.93 50.28 57.82 19307 1,013.03 962.38 1,106.74 20550 52.91 50.26 57.80 19316 690.52 655.99 754.39 # 20550 38.67 36.74 42.25 19318 1,013.11 962.45 1,106.82 20551 52.37 49.75 57.21 19324 422.84 401.70 461.96 # 20551 39.62 37.64 43.29 19325 573.77 545.08 626.84 20552 47.87 45.48 52.30 19328 433.80 412.11 473.93 # 20552 33.63 31.95 36.74 19330 556.68 528.85 608.18 20553 53.57 50.89 58.52 19340 357.65 339.77 390.74 # 20553 37.46 35.59 40.93 19342 818.52 777.59 894.23 20555 310.88 295.34 339.64 19350 754.69 716.96 824.50 20600 49.87 47.38 54.49 # 19350 602.93 572.78 658.70 # 20600 37.13 35.27 40.56 19355 626.74 595.40 684.71 20605 53.59 50.91 58.55 # 19355 498.58 473.65 544.70 # 20605 38.60 36.67 42.17 19357 1,376.96 1,308.11 1,504.33 20610 69.30 65.84 75.72 19361 1,478.81 1,404.87 1,615.60 # 20610 46.06 43.76 50.32 19364 2,508.57 2,383.14 2,740.61 20612 53.14 50.48 58.05 19366 1,234.76 1,173.02 1,348.97 # 20612 39.65 37.67 43.32 19367 1,624.40 1,543.18 1,774.66 20615 196.08 186.28 214.22 19368 2,007.51 1,907.13 2,193.20 # 20615 144.74 137.50 158.13 19369 1,833.60 1,741.92 2,003.21 20650 177.00 168.15 193.37 19370 604.30 574.09 660.20 # 20650 141.78 134.69 154.89 19371 695.85 661.06 760.22 20660 227.54 216.16 248.58 19380 681.90 647.81 744.98 # 20660 214.05 203.35 233.85 19396 196.43 186.61 214.60 20661 416.10 395.30 454.60 # 19396 119.99 113.99 131.09 20662 434.09 412.39 474.25 20000 183.65 174.47 200.64 20663 398.60 378.67 435.47 # 20000 140.56 133.53 153.56 20664 679.69 645.71 742.57 20005 271.35 257.78 296.45 20665 109.97 104.47 120.14 # 20005 214.40 203.68 234.23 # 20665 91.61 87.03 100.08 20100 530.63 504.10 579.72 20670 358.19 340.28 391.32 20101 353.93 336.23 386.66 # 20670 134.85 128.11 147.33 # 20101 181.92 172.82 198.74 20680 532.03 505.43 581.24 20102 414.06 393.36 452.36 # 20680 373.52 354.84 408.07 # 20102 222.20 211.09 242.75 20690 490.44 465.92 535.81 20103 502.30 477.19 548.77 20692 918.33 872.41 1,003.27 # 20103 316.81 300.97 346.12 20693 412.64 392.01 450.81 20150 864.85 821.61 944.85 20694 379.91 360.91 415.05 20200 171.91 163.31 187.81 # 20694 301.96 286.86 329.89 # 20200 83.85 79.66 91.61 20696 970.62 922.09 1,060.40 20205 233.78 222.09 255.40 20697 1,239.78 1,177.79 1,354.46 # 20205 133.72 127.03 146.08 # 20697 0.17 0.16 0.18 20206 243.72 231.53 266.26 20802 2,233.43 2,121.76 2,440.02 # 20206 59.73 56.74 65.25 20805 2,736.93 2,600.08 2,990.09 20220 166.30 157.99 181.69 20808 3,720.83 3,534.79 4,065.01 # 20220 74.49 70.77 81.39 20816 2,059.26 1,956.30 2,249.75 20225 636.21 604.40 695.06 20822 1,744.81 1,657.57 1,906.21 # 20225 112.33 106.71 122.72 20824 2,049.89 1,947.40 2,239.51 20240 206.61 196.28 225.72 20827 1,820.05 1,729.05 1,988.41 20245 563.35 535.18 615.46 20838 2,279.89 2,165.90 2,490.79 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 9 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 20900 379.06 360.11 414.13 # 21076 753.45 715.78 823.15 # 20900 237.78 225.89 259.77 21077 2,140.19 2,033.18 2,338.16 20902 327.37 311.00 357.65 # 21077 1,908.98 1,813.53 2,085.56 20910 390.19 370.68 426.28 21079 1,465.12 1,391.86 1,600.64 20912 437.91 416.01 478.41 # 21079 1,262.76 1,199.62 1,379.56 20920 368.36 349.94 402.43 21080 1,663.32 1,580.15 1,817.17 20922 549.90 522.41 600.77 # 21080 1,418.99 1,348.04 1,550.25 # 20922 451.72 429.13 493.50 21081 1,519.90 1,443.91 1,660.50 20924 454.37 431.65 496.40 # 21081 1,293.56 1,228.88 1,413.21 20926 392.45 372.83 428.75 21082 1,414.80 1,344.06 1,545.67 20931 101.67 96.59 111.08 # 21082 1,198.21 1,138.30 1,309.05 20937 155.72 147.93 170.12 21083 1,345.35 1,278.08 1,469.79 20938 168.68 160.25 184.29 # 21083 1,109.27 1,053.81 1,211.88 20950 224.15 212.94 244.88 21084 1,540.15 1,463.14 1,682.61 # 20950 82.50 78.38 90.14 # 21084 1,279.33 1,215.36 1,397.66 20955 2,321.34 2,205.27 2,536.06 21085 620.45 589.43 677.84 20956 2,408.76 2,288.32 2,631.57 # 21085 513.28 487.62 560.76 20957 2,287.92 2,173.52 2,499.55 21086 1,558.14 1,480.23 1,702.26 20962 2,364.92 2,246.67 2,583.67 # 21086 1,395.51 1,325.73 1,524.59 20969 2,574.45 2,445.73 2,812.59 21087 1,554.39 1,476.67 1,698.17 20970 2,574.87 2,446.13 2,813.05 # 21087 1,392.51 1,322.88 1,521.31 20972 2,346.83 2,229.49 2,563.91 21100 644.91 612.66 704.56 20973 2,461.61 2,338.53 2,689.31 # 21100 360.87 342.83 394.25 20974 59.04 56.09 64.50 21110 673.48 639.81 735.78 # 20974 43.31 41.14 47.31 # 21110 571.18 542.62 624.01 20975 161.10 153.05 176.01 21116 137.39 130.52 150.10 20979 48.22 45.81 52.68 # 21116 39.96 37.96 43.65 # 20979 32.85 31.21 35.89 21120 559.08 531.13 610.80 20982 3,516.63 3,340.80 3,841.92 # 21120 447.04 424.69 488.39 # 20982 382.75 363.61 418.15 21121 692.92 658.27 757.01 20985 137.89 131.00 150.65 # 21121 589.12 559.66 643.61 21010 656.32 623.50 717.03 21122 648.41 615.99 708.39 21015 384.15 364.94 419.68 21123 772.75 734.11 844.23 21025 794.30 754.59 867.78 21125 2,783.15 2,643.99 3,040.59 # 21025 673.26 639.60 735.54 # 21125 676.78 642.94 739.38 21026 529.83 503.34 578.84 21127 3,309.12 3,143.66 3,615.21 # 21026 436.52 414.69 476.89 # 21127 786.43 747.11 859.18 21029 671.07 637.52 733.15 21137 647.80 615.41 707.72 # 21029 565.39 537.12 617.69 21138 807.93 767.53 882.66 21030 442.56 420.43 483.49 21139 911.55 865.97 995.87 # 21030 361.99 343.89 395.47 21141 1,218.11 1,157.20 1,330.78 21031 341.05 324.00 372.60 21142 1,200.37 1,140.35 1,311.40 # 21031 258.98 246.03 282.93 21143 1,252.70 1,190.07 1,368.58 21032 345.72 328.43 377.69 21145 1,394.00 1,324.30 1,522.95 # 21032 255.04 242.29 278.63 21146 1,490.21 1,415.70 1,628.06 21034 1,195.41 1,135.64 1,305.99 21147 1,542.82 1,465.68 1,685.53 # 21034 1,060.13 1,007.12 1,158.19 21150 1,525.93 1,449.63 1,667.07 21040 446.30 423.99 487.59 21151 1,859.59 1,766.61 2,031.60 # 21040 359.74 341.75 393.01 21154 1,870.73 1,777.19 2,043.77 21044 794.98 755.23 868.51 21155 2,089.45 1,984.98 2,282.73 21045 1,107.53 1,052.15 1,209.97 21159 2,524.04 2,397.84 2,757.52 21046 980.02 931.02 1,070.67 21160 2,625.69 2,494.41 2,868.57 21047 1,178.64 1,119.71 1,287.67 21172 1,608.33 1,527.91 1,757.10 21048 993.19 943.53 1,085.06 21175 1,939.14 1,842.18 2,118.51 21049 1,144.09 1,086.89 1,249.92 21179 1,334.19 1,267.48 1,457.60 21050 779.46 740.49 851.56 21180 1,519.40 1,443.43 1,659.94 21060 710.65 675.12 776.39 21181 637.60 605.72 696.58 21070 577.30 548.44 630.71 21182 1,855.73 1,762.94 2,027.38 21073 329.62 313.14 360.11 21183 2,066.53 1,963.20 2,257.68 # 21073 214.58 203.85 234.43 21184 2,200.00 2,090.00 2,403.50 21076 867.74 824.35 948.00 21188 1,484.08 1,409.88 1,621.36 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 10 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 21193 1,121.80 1,065.71 1,225.57 21345 720.09 684.09 786.70 21194 1,284.74 1,220.50 1,403.58 # 21345 590.43 560.91 645.05 21195 1,213.78 1,153.09 1,326.05 21346 860.54 817.51 940.14 21196 1,320.31 1,254.29 1,442.43 21347 996.48 946.66 1,088.66 21198 1,042.10 990.00 1,138.50 21348 1,041.59 989.51 1,137.94 21199 934.74 888.00 1,021.20 21355 392.68 373.05 429.01 21206 1,026.95 975.60 1,121.94 # 21355 292.25 277.64 319.29 21208 1,564.36 1,486.14 1,709.06 21356 439.49 417.52 480.15 # 21208 746.32 709.00 815.35 # 21356 335.69 318.91 366.75 21209 733.56 696.88 801.41 21360 476.10 452.30 520.15 # 21209 575.80 547.01 629.06 21365 992.51 942.88 1,084.31 21210 1,876.66 1,782.83 2,050.25 21366 1,097.57 1,042.69 1,199.09 # 21210 743.10 705.95 811.84 21385 642.90 610.76 702.37 21215 3,217.15 3,056.29 3,514.73 21386 597.93 568.03 653.23 # 21215 773.15 734.49 844.66 21387 669.83 636.34 731.79 21230 691.32 656.75 755.26 21390 693.43 658.76 757.57 21235 651.54 618.96 711.80 21395 870.56 827.03 951.08 # 21235 511.39 485.82 558.69 21400 158.61 150.68 173.28 21240 997.11 947.25 1,089.34 # 21400 129.76 123.27 141.76 21242 916.16 870.35 1,000.90 21401 423.63 402.45 462.82 21243 1,499.96 1,424.96 1,638.70 # 21401 264.37 251.15 288.82 21244 945.25 897.99 1,032.69 21406 485.66 461.38 530.59 21245 1,024.36 973.14 1,119.11 21407 573.85 545.16 626.93 # 21245 828.75 787.31 905.41 21408 787.11 747.75 859.91 21246 770.10 731.60 841.34 21421 652.67 620.04 713.05 21247 1,459.96 1,386.96 1,595.00 # 21421 555.61 527.83 607.00 21248 959.26 911.30 1,048.00 21422 602.44 572.32 658.17 # 21248 791.00 751.45 864.17 21423 713.97 678.27 780.01 21249 1,325.06 1,258.81 1,447.63 21431 665.18 631.92 726.71 # 21249 1,118.21 1,062.30 1,221.65 21432 601.87 571.78 657.55 21255 1,302.26 1,237.15 1,422.72 21433 1,531.90 1,455.31 1,673.61 21256 1,059.11 1,006.15 1,157.07 21435 1,211.26 1,150.70 1,323.31 21260 1,205.72 1,145.43 1,317.24 21436 1,779.68 1,690.70 1,944.31 21261 2,036.94 1,935.09 2,225.35 21440 477.63 453.75 521.81 21263 1,836.05 1,744.25 2,005.89 # 21440 395.56 375.78 432.15 21267 1,403.10 1,332.95 1,532.89 21445 673.40 639.73 735.69 21268 1,725.72 1,639.43 1,885.34 # 21445 553.86 526.17 605.10 21270 819.74 778.75 895.56 21450 497.77 472.88 543.81 # 21270 633.12 601.46 691.68 # 21450 414.96 394.21 453.34 21275 727.22 690.86 794.49 21451 654.10 621.40 714.61 21280 474.30 450.59 518.18 # 21451 555.17 527.41 606.52 21282 314.82 299.08 343.94 21452 544.26 517.05 594.61 21295 157.87 149.98 172.48 # 21452 299.94 284.94 327.68 21296 383.57 364.39 419.05 21453 756.91 719.06 826.92 21310 96.70 91.87 105.65 # 21453 670.35 636.83 732.35 # 21310 26.25 24.94 28.68 21454 495.98 471.18 541.86 21315 235.54 223.76 257.32 21461 1,731.46 1,644.89 1,891.62 # 21315 133.61 126.93 145.97 # 21461 825.36 784.09 901.70 21320 225.97 214.67 246.87 21462 1,867.68 1,774.30 2,040.45 # 21320 124.04 117.84 135.52 # 21462 911.37 865.80 995.67 21325 425.14 403.88 464.46 21465 818.92 777.97 894.67 21330 518.47 492.55 566.43 21470 1,067.57 1,014.19 1,166.32 21335 666.07 632.77 727.69 21480 81.83 77.74 89.40 21336 578.90 549.96 632.45 # 21480 29.75 28.26 32.50 21337 350.83 333.29 383.28 21485 585.89 556.60 640.09 # 21337 256.40 243.58 280.12 # 21485 498.95 474.00 545.10 21338 663.31 630.14 724.66 21490 826.99 785.64 903.49 21339 736.80 699.96 804.95 21495 616.01 585.21 672.99 21340 726.46 690.14 793.66 21497 592.27 562.66 647.06 21343 1,037.78 985.89 1,133.77 # 21497 504.96 479.71 551.67 21344 1,352.53 1,284.90 1,477.64 21501 390.32 370.80 426.42 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 11 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 21501 282.40 268.28 308.52 22310 253.46 240.79 276.91 21502 467.76 444.37 511.03 # 22310 235.85 224.06 257.67 21510 415.14 394.38 453.54 22315 755.28 717.52 825.15 21550 230.58 219.05 251.91 # 22315 668.34 634.92 730.16 # 21550 144.01 136.81 157.33 22318 1,406.02 1,335.72 1,536.08 21555 382.75 363.61 418.15 22319 1,542.25 1,465.14 1,684.91 # 21555 296.18 281.37 323.58 22325 1,238.44 1,176.52 1,353.00 21556 370.52 351.99 404.79 22326 1,287.02 1,222.67 1,406.07 21557 521.09 495.04 569.30 22327 1,280.61 1,216.58 1,399.07 21600 495.85 471.06 541.72 22328 255.39 242.62 279.01 21610 950.62 903.09 1,038.55 22505 109.42 103.95 119.54 21615 603.98 573.78 659.85 22520 2,124.75 2,018.51 2,321.29 21616 772.35 733.73 843.79 # 22520 527.27 500.91 576.05 21620 470.18 446.67 513.67 22521 2,070.72 1,967.18 2,262.26 21627 494.80 470.06 540.57 # 22521 497.22 472.36 543.21 21630 1,145.11 1,087.85 1,251.03 22522 231.33 219.76 252.72 21632 1,130.21 1,073.70 1,234.76 22523 553.45 525.78 604.65 21685 901.70 856.62 985.11 22524 530.65 504.12 579.74 21700 384.42 365.20 419.98 22525 246.83 234.49 269.66 21705 582.22 553.11 636.08 22526 1,796.01 1,706.21 1,962.14 21720 366.49 348.17 400.40 # 22526 309.83 294.34 338.49 21725 476.34 452.52 520.40 22527 1,399.78 1,329.79 1,529.26 21740 982.48 933.36 1,073.36 # 22527 140.31 133.29 153.28 21750 651.61 619.03 711.88 22532 1,543.35 1,466.18 1,686.11 21800 87.06 82.71 95.12 22533 1,461.88 1,388.79 1,597.11 # 21800 88.56 84.13 96.75 22534 334.30 317.59 365.23 21805 231.73 220.14 253.16 22548 1,635.94 1,554.14 1,787.26 21810 448.86 426.42 490.38 22554 1,128.87 1,072.43 1,233.29 21820 115.87 110.08 126.59 22556 1,470.62 1,397.09 1,606.65 # 21820 117.37 111.50 128.23 22558 1,357.26 1,289.40 1,482.81 21825 509.88 484.39 557.05 22585 307.98 292.58 336.47 21920 230.24 218.73 251.54 22590 1,359.55 1,291.57 1,485.31 # 21920 144.05 136.85 157.38 22595 1,292.21 1,227.60 1,411.74 21925 373.47 354.80 408.02 22600 1,108.94 1,053.49 1,211.51 # 21925 300.40 285.38 328.19 22610 1,095.66 1,040.88 1,197.01 21930 416.83 395.99 455.39 22612 1,416.86 1,346.02 1,547.92 # 21930 332.89 316.25 363.69 22614 360.20 342.19 393.52 21935 1,042.24 990.13 1,138.65 22630 1,359.96 1,291.96 1,485.75 22010 807.99 767.59 882.73 22632 292.29 277.68 319.33 22015 803.69 763.51 878.04 22800 1,205.42 1,145.15 1,316.92 22100 726.09 689.79 793.26 22802 1,912.47 1,816.85 2,089.38 22101 725.89 689.60 793.04 22804 2,209.51 2,099.03 2,413.88 22102 723.14 686.98 790.03 22808 1,629.60 1,548.12 1,780.34 22103 130.32 123.80 142.37 22810 1,818.77 1,727.83 1,987.00 22110 900.25 855.24 983.53 22812 1,993.97 1,894.27 2,178.41 22112 871.79 828.20 952.43 22818 2,000.09 1,900.09 2,185.10 22114 894.98 850.23 977.76 22819 2,302.72 2,187.58 2,515.72 22116 129.10 122.65 141.05 22830 718.92 682.97 785.42 22206 2,136.77 2,029.93 2,334.42 22840 702.27 667.16 767.23 22207 2,109.70 2,004.22 2,304.85 22842 704.17 668.96 769.30 22208 532.41 505.79 581.66 22843 750.11 712.60 819.49 22210 1,566.92 1,488.57 1,711.86 22844 921.92 875.82 1,007.19 22212 1,301.45 1,236.38 1,421.84 22845 670.15 636.64 732.14 22214 1,309.82 1,244.33 1,430.98 22846 695.91 661.11 760.28 22216 338.66 321.73 369.99 22847 769.95 731.45 841.17 22220 1,409.26 1,338.80 1,539.62 22848 336.00 319.20 367.08 22222 1,284.92 1,220.67 1,403.77 22849 1,162.34 1,104.22 1,269.85 22224 1,401.34 1,331.27 1,530.96 22850 636.14 604.33 694.98 22226 337.16 320.30 368.35 22851 374.40 355.68 409.03 22305 163.96 155.76 179.12 22852 608.79 578.35 665.10 # 22305 150.84 143.30 164.80 22855 983.04 933.89 1,073.97 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 12 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 22856 1,466.40 1,393.08 1,602.04 23405 565.03 536.78 617.30 22857 1,546.22 1,468.91 1,689.25 23406 705.13 669.87 770.35 22861 1,796.64 1,706.81 1,962.83 23410 747.34 709.97 816.47 22862 1,773.08 1,684.43 1,937.09 23412 780.56 741.53 852.76 22864 1,630.18 1,548.67 1,780.97 23415 623.30 592.14 680.96 22865 1,906.98 1,811.63 2,083.37 23420 876.89 833.05 958.01 22900 366.02 347.72 399.88 23430 663.89 630.70 725.31 23000 473.18 449.52 516.95 23440 684.20 649.99 747.49 # 23000 319.54 303.56 349.09 23450 857.62 814.74 936.95 23020 617.48 586.61 674.60 23455 914.55 868.82 999.14 23030 377.52 358.64 412.44 23460 990.37 940.85 1,081.98 # 23030 229.50 218.03 250.73 23462 971.33 922.76 1,061.17 23031 345.91 328.61 377.90 23465 1,013.09 962.44 1,106.81 # 23031 190.40 180.88 208.01 23466 1,001.46 951.39 1,094.10 23035 613.22 582.56 669.94 23470 1,102.21 1,047.10 1,204.17 23040 643.04 610.89 702.52 23472 1,364.34 1,296.12 1,490.54 23044 510.41 484.89 557.62 23480 737.79 700.90 806.04 23065 191.24 181.68 208.93 23485 870.98 827.43 951.54 # 23065 150.02 142.52 163.90 23490 756.65 718.82 826.64 23066 450.13 427.62 491.76 23491 917.26 871.40 1,002.11 # 23066 302.11 287.00 330.05 23500 182.62 173.49 199.51 23075 230.11 218.60 251.39 # 23500 181.50 172.43 198.29 # 23075 158.54 150.61 173.20 23505 299.82 284.83 327.55 23076 502.55 477.42 549.03 # 23505 283.70 269.52 309.95 23077 1,064.68 1,011.45 1,163.17 23515 629.60 598.12 687.84 23100 434.83 413.09 475.05 23520 189.17 179.71 206.67 23101 399.67 379.69 436.64 # 23520 190.30 180.79 207.91 23105 568.75 540.31 621.36 23525 294.42 279.70 321.66 23106 424.36 403.14 463.61 # 23525 274.93 261.18 300.36 23107 590.73 561.19 645.37 23530 480.29 456.28 524.72 23120 512.09 486.49 559.46 23532 553.49 525.82 604.69 23125 627.79 596.40 685.86 23540 187.12 177.76 204.42 23130 538.55 511.62 588.36 # 23540 184.49 175.27 201.56 23140 457.81 434.92 500.16 23545 270.97 257.42 296.03 23145 617.34 586.47 674.44 # 23545 249.23 236.77 272.29 23146 535.92 509.12 585.49 23550 510.57 485.04 557.80 23150 584.84 555.60 638.94 23552 587.68 558.30 642.05 23155 706.84 671.50 772.23 23570 195.03 185.28 213.07 23156 601.05 571.00 656.65 # 23570 197.65 187.77 215.94 23170 472.59 448.96 516.30 23575 333.05 316.40 363.86 23172 485.98 461.68 530.93 # 23575 313.56 297.88 342.56 23174 672.72 639.08 734.94 23585 853.89 811.20 932.88 23180 612.74 582.10 669.42 23600 273.21 259.55 298.48 23182 591.75 562.16 646.48 # 23600 252.23 239.62 275.56 23184 666.96 633.61 728.65 23605 402.02 381.92 439.21 23190 496.67 471.84 542.62 # 23605 370.54 352.01 404.81 23195 672.49 638.87 734.70 23615 781.52 742.44 853.81 23200 793.17 753.51 866.54 23616 1,156.89 1,099.05 1,263.91 23210 829.98 788.48 906.75 23620 225.05 213.80 245.87 23220 960.09 912.09 1,048.90 # 23620 211.93 201.33 231.53 23221 1,118.56 1,062.63 1,222.02 23625 325.95 309.65 356.10 23222 1,524.09 1,447.89 1,665.07 # 23625 305.71 290.42 333.98 23330 199.60 189.62 218.06 23630 672.07 638.47 734.24 # 23330 132.90 126.26 145.20 23650 254.60 241.87 278.15 23331 524.36 498.14 572.86 # 23650 232.49 220.87 254.00 23332 794.19 754.48 867.65 23655 336.23 319.42 367.33 23350 146.11 138.80 159.62 23660 517.51 491.63 565.37 # 23350 50.93 48.38 55.64 23665 362.94 344.79 396.51 23395 1,156.45 1,098.63 1,263.42 # 23665 341.20 324.14 372.76 23397 1,034.43 982.71 1,130.12 23670 754.70 716.97 824.52 23400 877.52 833.64 958.69 23675 473.25 449.59 517.03 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 13 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 23675 437.28 415.42 477.73 24332 538.31 511.39 588.10 23680 815.23 774.47 890.64 24340 546.58 519.25 597.14 23700 173.89 165.20 189.98 24341 645.58 613.30 705.30 23800 923.78 877.59 1,009.23 24342 703.52 668.34 768.59 23802 1,122.43 1,066.31 1,226.26 24343 626.49 595.17 684.45 23900 1,193.76 1,134.07 1,304.18 24344 975.12 926.36 1,065.31 23920 968.93 920.48 1,058.55 24345 622.16 591.05 679.71 23921 352.11 334.50 384.68 24346 977.62 928.74 1,068.05 23930 313.65 297.97 342.67 24357 392.99 373.34 429.34 # 23930 192.99 183.34 210.84 24358 463.18 440.02 506.02 23931 246.07 233.77 268.84 24359 581.75 552.66 635.56 # 23931 140.02 133.02 152.97 24360 809.26 768.80 884.12 23935 441.87 419.78 482.75 24361 908.28 862.87 992.30 24000 420.32 399.30 459.20 24362 958.22 910.31 1,046.86 24006 635.39 603.62 694.16 24363 1,347.51 1,280.13 1,472.15 24065 225.09 213.84 245.92 24365 571.75 543.16 624.63 # 24065 149.77 142.28 163.62 24366 612.26 581.65 668.90 24066 518.56 492.63 566.52 24400 738.53 701.60 806.84 # 24066 353.68 336.00 386.40 24410 941.91 894.81 1,029.03 24075 421.59 400.51 460.59 24420 887.35 842.98 969.43 # 24075 277.32 263.45 302.97 24430 942.13 895.02 1,029.27 24076 422.09 400.99 461.14 24435 956.71 908.87 1,045.20 24077 728.51 692.08 795.89 24470 562.00 533.90 613.99 24100 358.66 340.73 391.84 24495 589.57 560.09 644.10 24101 442.02 419.92 482.91 24498 784.09 744.89 856.62 24102 547.69 520.31 598.36 24500 297.49 282.62 325.01 24105 298.04 283.14 325.61 # 24500 269.01 255.56 293.89 24110 518.22 492.31 566.16 24505 430.52 408.99 470.34 24115 653.22 620.56 713.64 # 24505 393.04 373.39 429.40 24116 775.00 736.25 846.69 24515 786.69 747.36 859.46 24120 464.19 440.98 507.13 24516 777.55 738.67 849.47 24125 537.75 510.86 587.49 24530 320.00 304.00 349.60 24126 570.59 542.06 623.37 # 24530 289.27 274.81 316.03 24130 448.76 426.32 490.27 24535 537.87 510.98 587.63 24134 673.40 639.73 735.69 # 24535 500.02 475.02 546.27 24136 531.09 504.54 580.22 24538 664.69 631.46 726.18 24138 589.95 560.45 644.52 24545 819.77 778.78 895.60 24140 642.20 610.09 701.60 24546 948.65 901.22 1,036.40 24145 538.74 511.80 588.57 24560 267.48 254.11 292.23 24147 560.20 532.19 612.02 # 24560 236.75 224.91 258.65 24149 1,034.91 983.16 1,130.63 24565 442.63 420.50 483.58 24150 873.94 830.24 954.78 # 24565 408.90 388.46 446.73 24151 1,004.75 954.51 1,097.69 24566 624.51 593.28 682.27 24152 659.29 626.33 720.28 24575 657.80 624.91 718.65 24153 711.57 675.99 777.39 24576 281.58 267.50 307.63 24155 761.41 723.34 831.84 # 24576 252.35 239.73 275.69 24160 539.31 512.34 589.19 24577 460.62 437.59 503.23 24164 441.06 419.01 481.86 # 24577 424.27 403.06 463.52 24200 174.70 165.97 190.87 24579 747.59 710.21 816.74 # 24200 120.74 114.70 131.91 24582 696.51 661.68 760.93 24201 487.42 463.05 532.51 24586 987.47 938.10 1,078.82 # 24201 322.91 306.76 352.77 24587 983.95 934.75 1,074.96 24220 159.88 151.89 174.67 24600 312.96 297.31 341.91 # 24220 67.32 63.95 73.54 # 24600 284.48 270.26 310.80 24300 347.91 330.51 380.09 24605 403.93 383.73 441.29 24301 674.26 640.55 736.63 24615 641.04 608.99 700.34 24305 515.99 490.19 563.72 24620 487.54 463.16 532.63 24310 422.34 401.22 461.40 24635 671.29 637.73 733.39 24320 694.02 659.32 758.22 24640 104.08 98.88 113.71 24330 640.73 608.69 699.99 # 24640 75.60 71.82 82.59 24331 708.43 673.01 773.96 24650 217.43 206.56 237.54 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 14 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 24650 196.07 186.27 214.21 25246 162.09 153.99 177.09 24655 374.10 355.40 408.71 # 25246 74.03 70.33 80.88 # 24655 342.25 325.14 373.91 25248 394.03 374.33 430.48 24665 577.78 548.89 631.22 25250 466.51 443.18 509.66 24666 655.58 622.80 716.22 25251 637.28 605.42 696.23 24670 244.13 231.92 266.71 25259 349.28 331.82 381.59 # 24670 218.65 207.72 238.88 25260 610.92 580.37 667.43 24675 394.61 374.88 431.11 25263 609.99 579.49 666.41 # 24675 362.75 344.61 396.30 25265 722.48 686.36 789.31 24685 579.62 550.64 633.24 25270 491.08 466.53 536.51 24800 711.68 676.10 777.52 25272 551.87 524.28 602.92 24802 899.58 854.60 982.79 25274 652.92 620.27 713.31 24900 642.80 610.66 702.26 25275 599.62 569.64 655.09 24920 637.79 605.90 696.79 25280 559.36 531.39 611.10 24925 496.78 471.94 542.73 25290 476.44 452.62 520.51 24930 676.57 642.74 739.15 25295 521.12 495.06 569.32 24931 753.77 716.08 823.49 25300 611.82 581.23 668.41 24935 915.83 870.04 1,000.55 25301 581.80 552.71 635.62 25000 310.86 295.32 339.62 25310 605.19 574.93 661.17 25001 293.28 278.62 320.41 25312 699.73 664.74 764.45 25020 514.49 488.77 562.09 25315 749.32 711.85 818.63 25023 984.54 935.31 1,075.61 25316 866.35 823.03 946.48 25024 687.11 652.75 750.66 25320 863.05 819.90 942.89 25025 1,059.62 1,006.64 1,157.64 25332 757.44 719.57 827.51 25028 458.34 435.42 500.73 25335 861.17 818.11 940.83 25031 336.26 319.45 367.37 25337 793.18 753.52 866.55 25035 580.02 551.02 633.67 25350 664.87 631.63 726.37 25040 511.25 485.69 558.54 25355 746.20 708.89 815.22 25065 223.76 212.57 244.46 25360 645.42 613.15 705.12 # 25065 148.07 140.67 161.77 25365 874.67 830.94 955.58 25066 336.80 319.96 367.95 25370 953.89 906.20 1,042.13 25075 294.64 279.91 321.90 25375 920.19 874.18 1,005.31 25076 398.43 378.51 435.29 25390 751.21 713.65 820.70 25077 671.51 637.93 733.62 25391 952.43 904.81 1,040.53 25085 413.32 392.65 451.55 25392 967.79 919.40 1,057.31 25100 307.45 292.08 335.89 25393 1,083.93 1,029.73 1,184.19 25101 361.83 343.74 395.30 25394 696.44 661.62 760.86 25105 439.46 417.49 480.11 25400 787.12 747.76 859.92 25107 547.43 520.06 598.07 25405 999.33 949.36 1,091.76 25109 465.84 442.55 508.93 25415 939.70 892.72 1,026.63 25110 322.53 306.40 352.36 25420 1,117.11 1,061.25 1,220.44 25111 279.80 265.81 305.68 25425 969.42 920.95 1,059.09 25112 340.98 323.93 372.52 25426 1,007.72 957.33 1,100.93 25115 721.78 685.69 788.54 25430 636.88 605.04 695.80 25116 584.45 555.23 638.51 25431 700.97 665.92 765.81 25118 342.37 325.25 374.04 25440 699.19 664.23 763.86 25119 452.60 429.97 494.47 25441 845.82 803.53 924.06 25120 498.52 473.59 544.63 25442 723.16 687.00 790.05 25125 580.38 551.36 634.06 25443 694.54 659.81 758.78 25126 584.53 555.30 638.60 25444 738.65 701.72 806.98 25130 401.56 381.48 438.70 25445 646.52 614.19 706.32 25135 500.73 475.69 547.04 25446 1,063.44 1,010.27 1,161.81 25136 441.87 419.78 482.75 25447 730.91 694.36 798.51 25145 511.80 486.21 559.14 25449 931.64 885.06 1,017.82 25150 518.41 492.49 566.36 25450 541.74 514.65 591.85 25151 575.23 546.47 628.44 25455 621.22 590.16 678.68 25170 798.02 758.12 871.84 25490 684.08 649.88 747.36 25210 439.77 417.78 480.45 25491 721.55 685.47 788.29 25215 565.77 537.48 618.10 25492 866.98 823.63 947.17 25230 389.46 369.99 425.49 25500 222.64 211.51 243.24 25240 395.13 375.37 431.68 # 25500 202.41 192.29 221.13 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 15 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 25505 432.49 410.87 472.50 25920 613.27 582.61 670.00 # 25505 398.76 378.82 435.64 25922 518.44 492.52 566.40 25515 595.55 565.77 650.64 25924 598.84 568.90 654.24 25520 475.61 451.83 519.60 25927 700.66 665.63 765.47 # 25520 452.75 430.11 494.63 25929 500.17 475.16 546.43 25525 718.28 682.37 784.73 25931 639.06 607.11 698.18 25526 884.81 840.57 966.66 26010 224.15 212.94 244.88 25530 216.24 205.43 236.24 # 26010 117.35 111.48 128.20 # 25530 193.75 184.06 211.67 26011 341.90 324.81 373.53 25535 418.94 397.99 457.69 # 26011 163.15 154.99 178.24 # 25535 391.96 372.36 428.21 26020 376.91 358.06 411.77 25545 557.54 529.66 609.11 26025 367.64 349.26 401.65 25560 225.66 214.38 246.54 26030 433.86 412.17 474.00 # 25560 201.30 191.24 219.93 26034 470.49 446.97 514.02 25565 452.65 430.02 494.52 26035 732.06 695.46 799.78 # 25565 413.67 392.99 451.94 26037 505.58 480.30 552.35 25574 588.47 559.05 642.91 26040 270.51 256.98 295.53 25575 798.74 758.80 872.62 26045 410.80 390.26 448.80 25600 245.67 233.39 268.40 26055 500.59 475.56 546.89 # 25600 221.31 210.24 241.78 # 26055 260.39 247.37 284.48 25605 532.16 505.55 581.38 26060 231.70 220.12 253.14 # 25605 502.93 477.78 549.45 26070 263.19 250.03 287.53 25606 589.69 560.21 644.24 26075 278.87 264.93 304.67 25607 636.06 604.26 694.90 26080 336.88 320.04 368.05 25608 722.88 686.74 789.75 26100 282.95 268.80 309.12 25609 922.15 876.04 1,007.45 26105 289.35 274.88 316.11 25622 252.26 239.65 275.60 26110 278.11 264.20 303.83 # 25622 226.40 215.08 247.34 26115 547.30 519.94 597.93 25624 397.76 377.87 434.55 # 26115 315.72 299.93 344.92 # 25624 362.54 344.41 396.07 26116 423.93 402.73 463.14 25628 638.63 606.70 697.71 26117 576.21 547.40 629.51 25630 257.81 244.92 281.66 26121 530.04 503.54 579.07 # 25630 232.32 220.70 253.81 26123 726.49 690.17 793.70 25635 375.90 357.11 410.68 26125 257.01 244.16 280.78 # 25635 334.68 317.95 365.64 26130 401.42 381.35 438.55 25645 503.24 478.08 549.79 26135 488.74 464.30 533.95 25650 268.79 255.35 293.65 26140 445.00 422.75 486.16 # 25650 247.06 234.71 269.92 26145 452.00 429.40 493.81 25651 418.17 397.26 456.85 26160 499.82 474.83 546.05 25652 549.39 521.92 600.21 # 26160 283.22 269.06 309.42 25660 350.23 332.72 382.63 26170 356.22 338.41 389.17 25670 542.97 515.82 593.19 26180 389.35 369.88 425.36 25671 459.70 436.72 502.23 26185 466.28 442.97 509.42 25675 370.51 351.98 404.78 26200 398.81 378.87 435.70 # 25675 340.91 323.86 372.44 26205 535.12 508.36 584.61 25676 562.44 534.32 614.47 26210 387.31 367.94 423.13 25680 402.78 382.64 440.04 26215 491.54 466.96 537.00 25685 653.05 620.40 713.46 26230 445.92 423.62 487.16 25690 407.40 387.03 445.08 26235 438.37 416.45 478.92 25695 564.03 535.83 616.20 26236 388.92 369.47 424.89 25800 667.20 633.84 728.92 26250 517.88 491.99 565.79 25805 768.94 730.49 840.06 26255 785.48 746.21 858.14 25810 777.42 738.55 849.33 26260 485.01 460.76 529.87 25820 547.12 519.76 597.72 26261 601.02 570.97 656.62 25825 674.48 640.76 736.87 26262 404.96 384.71 442.42 25830 847.19 804.83 925.55 26320 303.21 288.05 331.26 25900 673.13 639.47 735.39 26340 275.24 261.48 300.70 25905 664.28 631.07 725.73 26350 637.63 605.75 696.61 25907 581.57 552.49 635.36 26352 722.92 686.77 789.79 25909 652.97 620.32 713.37 26356 946.74 899.40 1,034.31 25915 1,136.75 1,079.91 1,241.90 26357 774.82 736.08 846.49 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 16 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 26358 819.45 778.48 895.25 26550 1,331.62 1,265.04 1,454.80 26370 688.34 653.92 752.01 26551 2,876.74 2,732.90 3,142.84 26372 796.26 756.45 869.92 26553 2,544.33 2,417.11 2,779.68 26373 757.92 720.02 828.02 26554 3,286.33 3,122.01 3,590.31 26390 740.21 703.20 808.68 26555 1,226.55 1,165.22 1,340.00 26392 867.07 823.72 947.28 26556 2,628.06 2,496.66 2,871.16 26410 507.35 481.98 554.28 26560 507.54 482.16 554.48 26412 614.27 583.56 671.09 26561 809.52 769.04 884.40 26415 643.43 611.26 702.95 26562 1,176.67 1,117.84 1,285.52 26416 690.52 655.99 754.39 26565 603.30 573.14 659.11 26418 510.59 485.06 557.82 26567 609.10 578.65 665.45 26420 637.40 605.53 696.36 26568 800.77 760.73 874.84 26426 511.11 485.55 558.38 26580 1,247.34 1,184.97 1,362.72 26428 670.07 636.57 732.06 26587 852.56 809.93 931.42 26432 443.75 421.56 484.79 26590 1,128.37 1,071.95 1,232.74 26433 475.43 451.66 519.41 26591 391.20 371.64 427.39 26434 568.94 540.49 621.56 26593 531.55 504.97 580.72 26437 554.79 527.05 606.11 26596 651.56 618.98 711.83 26440 559.97 531.97 611.77 26600 235.72 223.93 257.52 26442 844.53 802.30 922.65 # 26600 217.36 206.49 237.46 26445 520.70 494.67 568.87 26605 270.87 257.33 295.93 26449 675.95 642.15 738.47 # 26605 246.51 234.18 269.31 26450 357.98 340.08 391.09 26607 385.38 366.11 421.03 26455 355.61 337.83 388.50 26608 418.48 397.56 457.19 26460 346.00 328.70 378.01 26615 485.77 461.48 530.70 26471 546.51 519.18 597.06 26641 311.51 295.93 340.32 26474 525.22 498.96 573.80 # 26641 284.16 269.95 310.44 26476 510.93 485.38 558.19 26645 354.13 336.42 386.88 26477 515.43 489.66 563.11 # 26645 326.02 309.72 356.18 26478 559.11 531.15 610.82 26650 418.69 397.76 457.42 26479 552.78 525.14 603.91 26665 539.55 512.57 589.46 26480 673.76 640.07 736.08 26670 280.79 266.75 306.76 26483 758.70 720.77 828.89 # 26670 252.68 240.05 276.06 26485 727.72 691.33 795.03 26675 377.56 358.68 412.48 26489 784.49 745.27 857.06 # 26675 348.34 330.92 380.56 26490 700.74 665.70 765.56 26676 438.98 417.03 479.58 26492 780.13 741.12 852.29 26685 497.09 472.24 543.08 26494 708.94 673.49 774.51 26686 550.06 522.56 600.94 26496 767.91 729.51 838.94 26700 267.76 254.37 292.53 26497 768.77 730.33 839.88 # 26700 249.02 236.57 272.06 26498 1,023.40 972.23 1,118.06 26705 346.76 329.42 378.83 26499 734.87 698.13 802.85 # 26705 317.91 302.01 347.31 26500 557.76 529.87 609.35 26706 379.80 360.81 414.93 26502 628.13 596.72 686.23 26715 486.28 461.97 531.27 26508 560.15 532.14 611.96 26720 163.12 154.96 178.20 26510 532.69 506.06 581.97 # 26720 148.88 141.44 162.66 26516 626.50 595.18 684.46 26725 290.36 275.84 317.22 26517 736.00 699.20 804.08 # 26725 260.00 247.00 284.05 26518 743.35 706.18 812.11 26727 411.63 391.05 449.71 26520 585.13 555.87 639.25 26735 506.26 480.95 553.09 26525 587.50 558.13 641.85 26740 189.73 180.24 207.28 26530 473.99 450.29 517.83 # 26740 177.74 168.85 194.18 26531 551.99 524.39 603.05 26742 317.83 301.94 347.23 26535 355.50 337.73 388.39 # 26742 288.23 273.82 314.89 26536 598.64 568.71 654.02 26746 620.73 589.69 678.14 26540 588.95 559.50 643.43 26750 152.24 144.63 166.32 26541 718.10 682.20 784.53 # 26750 148.11 140.70 161.81 26542 608.82 578.38 665.14 26755 267.13 253.77 291.84 26545 619.60 588.62 676.91 # 26755 231.90 220.31 253.36 26546 869.19 825.73 949.59 26756 363.43 345.26 397.05 26548 681.25 647.19 744.27 26765 412.94 392.29 451.13 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 17 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 26770 227.64 216.26 248.70 27087 565.96 537.66 618.31 # 26770 207.78 197.39 227.00 27090 748.07 710.67 817.27 26775 324.45 308.23 354.46 27091 1,446.29 1,373.98 1,580.08 # 26775 290.73 276.19 317.62 27093 179.08 170.13 195.65 26776 386.33 367.01 422.06 # 27093 67.79 64.40 74.06 26785 450.45 427.93 492.12 27095 216.44 205.62 236.46 26820 701.70 666.62 766.61 # 27095 77.42 73.55 84.58 26841 650.69 618.16 710.88 27096 164.25 156.04 179.45 26842 705.72 670.43 770.99 # 27096 64.94 61.69 70.94 26843 654.04 621.34 714.54 27097 596.36 566.54 651.52 26844 728.81 692.37 796.23 27098 559.74 531.75 611.51 26850 620.46 589.44 677.86 27100 736.21 699.40 804.31 26852 710.49 674.97 776.22 27105 772.42 733.80 843.87 26860 500.11 475.10 546.37 27110 860.09 817.09 939.65 26861 96.86 92.02 105.82 27111 766.68 728.35 837.60 26862 646.78 614.44 706.61 27120 1,164.56 1,106.33 1,272.28 26863 216.33 205.51 236.34 27122 998.15 948.24 1,090.48 26910 635.47 603.70 694.26 27125 1,016.87 966.03 1,110.93 26951 552.96 525.31 604.11 27130 1,309.30 1,243.84 1,430.42 26952 577.59 548.71 631.02 27132 1,530.18 1,453.67 1,671.72 26990 549.66 522.18 600.51 27134 1,772.49 1,683.87 1,936.45 26991 619.50 588.53 676.81 27137 1,352.03 1,284.43 1,477.09 # 26991 462.87 439.73 505.69 27138 1,407.04 1,336.69 1,537.19 26992 862.75 819.61 942.55 27140 810.45 769.93 885.42 27000 398.46 378.54 435.32 27146 1,142.11 1,085.00 1,247.75 27001 482.53 458.40 527.16 27147 1,329.96 1,263.46 1,452.98 27003 519.72 493.73 567.79 27151 1,382.21 1,313.10 1,510.07 27005 653.36 620.69 713.79 27156 1,550.62 1,473.09 1,694.05 27006 660.69 627.66 721.81 27158 1,248.06 1,185.66 1,363.51 27025 801.08 761.03 875.18 27161 1,104.55 1,049.32 1,206.72 27027 780.42 741.40 852.61 27165 1,235.11 1,173.35 1,349.35 27030 852.18 809.57 931.01 27170 1,068.68 1,015.25 1,167.54 27033 882.53 838.40 964.16 27175 595.47 565.70 650.56 27035 988.68 939.25 1,080.14 27176 821.48 780.41 897.47 27036 903.37 858.20 986.93 27177 1,002.66 952.53 1,095.41 27040 305.47 290.20 333.73 27178 813.53 772.85 888.78 # 27040 182.93 173.78 199.85 27179 876.34 832.52 957.40 27041 618.39 587.47 675.59 27181 982.86 933.72 1,073.78 27047 552.21 524.60 603.29 27185 612.84 582.20 669.53 # 27047 461.15 438.09 503.80 27187 898.21 853.30 981.30 27048 424.85 403.61 464.15 27193 412.67 392.04 450.85 27049 897.48 852.61 980.50 # 27193 416.42 395.60 454.94 27050 311.49 295.92 340.31 27194 640.99 608.94 700.28 27052 496.42 471.60 542.34 27200 150.80 143.26 164.75 27054 608.28 577.87 664.55 # 27200 154.18 146.47 168.44 27057 869.81 826.32 950.27 27202 576.31 547.49 629.61 27060 383.68 364.50 419.18 27220 465.18 441.92 508.21 27062 400.63 380.60 437.69 # 27220 461.80 438.71 504.52 27065 446.96 424.61 488.30 27222 881.14 837.08 962.64 27066 724.55 688.32 791.57 27226 935.60 888.82 1,022.14 27067 922.05 875.95 1,007.34 27227 1,515.38 1,439.61 1,655.55 27070 760.28 722.27 830.61 27228 1,735.13 1,648.37 1,895.63 27071 815.73 774.94 891.18 27230 414.41 393.69 452.74 27075 2,087.88 1,983.49 2,281.01 # 27230 408.79 388.35 446.60 27076 1,443.82 1,371.63 1,577.37 27232 698.10 663.20 762.68 27077 2,416.40 2,295.58 2,639.92 27235 821.76 780.67 897.77 27078 914.56 868.83 999.15 27236 1,074.93 1,021.18 1,174.36 27079 875.28 831.52 956.25 27238 400.74 380.70 437.81 27080 440.62 418.59 481.38 27240 859.72 816.73 939.24 27086 218.85 207.91 239.10 27244 1,105.85 1,050.56 1,208.14 # 27086 132.66 126.03 144.93 27245 1,141.96 1,084.86 1,247.59 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 18 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 27246 338.83 321.89 370.17 27381 718.02 682.12 784.44 # 27246 339.58 322.60 370.99 27385 564.51 536.28 616.72 27248 678.26 644.35 741.00 27386 744.76 707.52 813.65 27250 212.56 201.93 232.22 27390 391.03 371.48 427.20 27252 679.32 645.35 742.15 27391 509.26 483.80 556.37 27253 853.46 810.79 932.41 27392 626.97 595.62 684.96 27254 1,151.86 1,094.27 1,258.41 27393 451.37 428.80 493.12 27256 262.13 249.02 286.37 27394 583.00 553.85 636.93 # 27256 220.16 209.15 240.52 27395 789.09 749.64 862.09 27257 302.63 287.50 330.63 27396 548.38 520.96 599.10 27258 1,000.39 950.37 1,092.93 27397 808.52 768.09 883.30 27259 1,402.36 1,332.24 1,532.08 27400 612.19 581.58 668.82 27265 348.05 330.65 380.25 27403 573.75 545.06 626.82 27266 516.97 491.12 564.79 27405 604.63 574.40 660.56 27267 369.25 350.79 403.41 27407 689.65 655.17 753.45 27268 456.54 433.71 498.77 27409 867.55 824.17 947.80 27269 1,095.68 1,040.90 1,197.04 27412 1,498.10 1,423.20 1,636.68 27275 160.66 152.63 175.52 27415 1,249.20 1,186.74 1,364.75 27280 925.42 879.15 1,011.02 27416 868.48 825.06 948.82 27282 725.55 689.27 792.66 27418 749.10 711.65 818.40 27284 1,403.46 1,333.29 1,533.28 27420 670.55 637.02 732.57 27286 1,493.48 1,418.81 1,631.63 27422 667.83 634.44 729.61 27290 1,421.53 1,350.45 1,553.02 27424 669.66 636.18 731.61 27295 1,146.78 1,089.44 1,252.86 27425 391.67 372.09 427.90 27301 584.66 555.43 638.74 27427 643.11 610.95 702.59 # 27301 440.76 418.72 481.53 27428 990.98 941.43 1,082.64 27303 570.57 542.04 623.35 27429 1,109.88 1,054.39 1,212.55 27305 416.35 395.53 454.86 27430 663.61 630.43 724.99 27306 337.00 320.15 368.17 27435 712.93 677.28 778.87 27307 414.77 394.03 453.13 27437 590.26 560.75 644.86 27310 650.72 618.18 710.91 27438 755.82 718.03 825.73 27323 237.22 225.36 259.16 27440 689.79 655.30 753.60 # 27323 160.02 152.02 174.82 27441 712.06 676.46 777.93 27324 339.80 322.81 371.23 27442 782.21 743.10 854.57 27325 470.23 446.72 513.73 27443 733.18 696.52 801.00 27326 433.66 411.98 473.78 27445 1,141.01 1,083.96 1,246.55 27327 399.27 379.31 436.21 27446 1,011.37 960.80 1,104.92 # 27327 310.84 295.30 339.60 27447 1,401.68 1,331.60 1,531.34 27328 374.45 355.73 409.09 27448 738.08 701.18 806.36 27329 932.61 885.98 1,018.88 27450 919.87 873.88 1,004.96 27330 355.77 337.98 388.68 27454 1,159.41 1,101.44 1,266.66 27331 420.49 399.47 459.39 27455 850.02 807.52 928.65 27332 570.07 541.57 622.81 27457 875.09 831.34 956.04 27333 516.81 490.97 564.62 27465 1,105.11 1,049.85 1,207.33 27334 606.73 576.39 662.85 27466 1,069.98 1,016.48 1,168.95 27335 686.01 651.71 749.47 27468 1,210.30 1,149.79 1,322.26 27340 322.70 306.57 352.56 27470 1,066.79 1,013.45 1,165.47 27345 426.08 404.78 465.50 27472 1,152.77 1,095.13 1,259.40 27347 457.50 434.63 499.82 27475 588.09 558.69 642.49 27350 580.33 551.31 634.01 27477 657.55 624.67 718.37 27355 537.77 510.88 587.51 27479 842.44 800.32 920.37 27356 659.13 626.17 720.10 27485 600.76 570.72 656.33 27357 729.90 693.41 797.42 27486 1,279.46 1,215.49 1,397.81 27358 264.45 251.23 288.91 27487 1,612.71 1,532.07 1,761.88 27360 761.55 723.47 831.99 27488 1,083.34 1,029.17 1,183.55 27365 1,107.41 1,052.04 1,209.85 27495 1,025.41 974.14 1,120.26 27370 153.62 145.94 167.83 27496 448.94 426.49 490.46 # 27370 49.45 46.98 54.03 27497 486.49 462.17 531.50 27372 527.30 500.94 576.08 27498 530.28 503.77 579.34 # 27372 359.04 341.09 392.25 27499 587.74 558.35 642.10 27380 527.47 501.10 576.27 27500 452.69 430.06 494.57 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 19 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 27500 420.47 399.45 459.37 27613 222.84 211.70 243.46 27501 444.43 422.21 485.54 # 27613 150.52 142.99 164.44 # 27501 438.06 416.16 478.58 27614 498.49 473.57 544.61 27502 707.27 671.91 772.70 # 27614 370.33 351.81 404.58 27503 720.04 684.04 786.65 27615 794.16 754.45 867.62 27506 1,204.12 1,143.91 1,315.50 27618 434.58 412.85 474.78 27507 890.75 846.21 973.14 # 27618 343.52 326.34 375.29 27508 457.29 434.43 499.59 27619 692.05 657.45 756.07 # 27508 431.06 409.51 470.94 # 27619 530.92 504.37 580.03 27509 574.64 545.91 627.80 27620 415.75 394.96 454.20 27510 625.69 594.41 683.57 27625 537.18 510.32 586.87 27511 923.58 877.40 1,009.01 27626 579.37 550.40 632.96 27513 1,160.34 1,102.32 1,267.67 27630 477.30 453.44 521.46 27514 929.55 883.07 1,015.53 # 27630 334.90 318.16 365.88 27516 428.90 407.46 468.58 27635 534.20 507.49 583.61 # 27516 404.17 383.96 441.55 27637 677.38 643.51 740.04 27517 602.77 572.63 658.52 27638 704.67 669.44 769.86 27519 841.88 799.79 919.76 27640 781.92 742.82 854.24 27520 271.27 257.71 296.37 27641 627.08 595.73 685.09 # 27520 245.04 232.79 267.71 27645 947.37 900.00 1,035.00 27524 677.27 643.41 739.92 27646 838.28 796.37 915.83 27530 339.88 322.89 371.32 27647 740.48 703.46 808.98 # 27530 315.90 300.11 345.13 27648 148.00 140.60 161.69 27532 541.16 514.10 591.22 # 27648 49.07 46.62 53.61 # 27532 511.56 485.98 558.88 27650 609.66 579.18 666.06 27535 825.37 784.10 901.72 27652 670.60 637.07 732.63 27536 1,072.97 1,019.32 1,172.22 27654 655.60 622.82 716.24 27538 406.12 385.81 443.68 27656 480.91 456.86 525.39 # 27538 380.27 361.26 415.45 # 27656 316.40 300.58 345.67 27540 746.28 708.97 815.32 27658 346.72 329.38 378.79 27550 429.77 408.28 469.52 27659 454.64 431.91 496.70 # 27550 399.79 379.80 436.77 27664 330.65 314.12 361.24 27552 553.21 525.55 604.38 27665 378.51 359.58 413.52 27556 827.91 786.51 904.49 27675 463.24 440.08 506.09 27557 990.55 941.02 1,082.17 27676 562.32 534.20 614.33 27558 1,112.92 1,057.27 1,215.86 27680 392.58 372.95 428.89 27560 316.36 300.54 345.62 27681 467.32 443.95 510.54 # 27560 286.38 272.06 312.87 27685 564.52 536.29 616.73 27562 408.76 388.32 446.57 # 27685 433.37 411.70 473.46 27566 805.84 765.55 880.38 27686 510.18 484.67 557.37 27570 131.43 124.86 143.59 27687 420.01 399.01 458.86 27580 1,306.63 1,241.30 1,427.50 27690 578.40 549.48 631.90 27590 747.48 710.11 816.63 27691 678.39 644.47 741.14 27591 828.68 787.25 905.34 27692 102.38 97.26 111.85 27592 635.06 603.31 693.81 27695 447.43 425.06 488.82 27594 460.34 437.32 502.92 27696 533.30 506.64 582.64 27596 665.13 631.87 726.65 27698 598.73 568.79 654.11 27598 675.93 642.13 738.45 27700 566.22 537.91 618.60 27600 382.21 363.10 417.57 27702 903.56 858.38 987.14 27601 397.32 377.45 434.07 27703 1,045.18 992.92 1,141.86 27602 467.66 444.28 510.92 27704 512.86 487.22 560.30 27603 464.18 440.97 507.12 27705 693.69 659.01 757.86 # 27603 346.88 329.54 378.97 27707 354.60 336.87 387.40 27604 406.87 386.53 444.51 27709 1,017.91 967.01 1,112.06 # 27604 305.31 290.04 333.55 27712 989.46 939.99 1,080.99 27605 326.54 310.21 356.74 27715 965.50 917.23 1,054.81 # 27605 182.64 173.51 199.54 27720 794.16 754.45 867.62 27606 267.97 254.57 292.76 27722 791.96 752.36 865.21 27607 552.84 525.20 603.98 27724 1,163.90 1,105.71 1,271.57 27610 590.36 560.84 644.97 27725 1,085.44 1,031.17 1,185.85 27612 515.70 489.92 563.41 27726 830.89 789.35 907.75 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 20 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 27727 878.13 834.22 959.35 27870 951.18 903.62 1,039.16 27730 526.29 499.98 574.98 27871 625.18 593.92 683.01 27732 360.52 342.49 393.86 27880 840.54 798.51 918.29 27734 538.23 511.32 588.02 27881 810.35 769.83 885.30 27740 596.73 566.89 651.92 27882 571.49 542.92 624.36 27742 626.80 595.46 684.78 27884 531.68 505.10 580.87 27745 681.39 647.32 744.42 27886 606.38 576.06 662.47 27750 292.75 278.11 319.83 27888 641.45 609.38 700.79 # 27750 268.02 254.62 292.81 27889 625.31 594.04 683.15 27752 469.85 446.36 513.31 27892 492.61 467.98 538.18 # 27752 437.62 415.74 478.10 27893 499.03 474.08 545.19 27756 508.33 482.91 555.35 27894 765.86 727.57 836.71 27758 800.49 760.47 874.54 28001 241.83 229.74 264.20 27759 906.31 860.99 990.14 # 28001 167.64 159.26 183.15 27760 282.45 268.33 308.58 28002 449.84 427.35 491.45 # 27760 255.85 243.06 279.52 # 28002 354.28 336.57 387.06 27762 421.12 400.06 460.07 28003 616.14 585.33 673.13 # 27762 388.52 369.09 424.45 # 28003 519.46 493.49 567.51 27766 545.99 518.69 596.49 28005 567.22 538.86 619.69 27767 224.82 213.58 245.62 28008 381.27 362.21 416.54 # 27767 225.95 214.65 246.85 # 28008 283.84 269.65 310.10 27768 358.75 340.81 391.93 28010 211.03 200.48 230.55 27769 622.41 591.29 679.98 # 28010 197.17 187.31 215.41 27780 252.95 240.30 276.35 28011 298.10 283.20 325.68 # 27780 228.59 217.16 249.73 # 28011 277.12 263.26 302.75 27781 364.87 346.63 398.62 28020 452.68 430.05 494.56 # 27781 339.76 322.77 371.19 # 28020 333.15 316.49 363.96 27784 621.68 590.60 679.19 28022 418.15 397.24 456.83 27786 267.76 254.37 292.53 # 28022 308.72 293.28 337.27 # 27786 240.40 228.38 262.64 28024 397.65 377.77 434.44 27788 367.96 349.56 401.99 # 28024 292.73 278.09 319.80 # 27788 338.73 321.79 370.06 28035 455.61 432.83 497.75 27792 627.99 596.59 686.08 # 28035 336.45 319.63 367.57 27808 280.50 266.48 306.45 28043 303.54 288.36 331.61 # 27808 251.27 238.71 274.52 # 28043 242.08 229.98 264.48 27810 412.18 391.57 450.31 28045 426.11 404.80 465.52 # 27810 378.83 359.89 413.87 # 28045 306.95 291.60 335.34 27814 698.29 663.38 762.89 28046 771.15 732.59 842.48 27816 265.31 252.04 289.85 # 28046 625.75 594.46 683.63 # 27816 238.33 226.41 260.37 28050 400.79 380.75 437.86 27818 424.78 403.54 464.07 # 28050 290.24 275.73 317.09 # 27818 386.93 367.58 422.72 28052 369.72 351.23 403.91 27822 766.32 728.00 837.20 # 28052 264.05 250.85 288.48 27823 871.92 828.32 952.57 28054 347.88 330.49 380.06 27824 266.06 252.76 290.67 # 28054 241.09 229.04 263.40 # 27824 255.94 243.14 279.61 28055 368.22 349.81 402.28 27825 482.87 458.73 527.54 28060 448.66 426.23 490.16 # 27825 443.15 420.99 484.14 # 28060 337.73 320.84 368.97 27826 737.61 700.73 805.84 28062 527.33 500.96 576.10 27827 979.87 930.88 1,070.51 # 28062 395.42 375.65 432.00 27828 1,171.44 1,112.87 1,279.80 28070 444.86 422.62 486.01 27829 591.26 561.70 645.96 # 28070 330.19 313.68 360.73 27830 308.99 293.54 337.57 28072 439.51 417.53 480.16 # 27830 289.13 274.67 315.87 # 28072 320.34 304.32 349.97 27831 335.80 319.01 366.86 28080 432.61 410.98 472.63 27832 635.26 603.50 694.03 # 28080 325.43 309.16 355.53 27840 310.65 295.12 339.39 28086 471.66 448.08 515.29 27842 432.32 410.70 472.31 # 28086 334.14 317.43 365.04 27846 666.61 633.28 728.27 28088 400.77 380.73 437.84 27848 754.45 716.73 824.24 # 28088 278.61 264.68 304.38 27860 161.32 153.25 176.24 28090 404.15 383.94 441.53 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 21 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 28090 291.35 276.78 318.30 # 28202 418.70 397.77 457.44 28092 365.71 347.42 399.53 28208 398.41 378.49 435.26 # 28092 256.29 243.48 280.00 # 28208 288.99 274.54 315.72 28100 520.87 494.83 569.05 28210 511.12 485.56 558.39 # 28100 378.10 359.20 413.08 # 28210 391.58 372.00 427.80 28102 515.79 490.00 563.50 28220 393.15 373.49 429.51 28103 416.27 395.46 454.78 # 28220 291.60 277.02 318.57 28104 446.58 424.25 487.89 28222 453.58 430.90 495.54 # 28104 330.78 314.24 361.38 # 28222 346.78 329.44 378.86 28106 439.18 417.22 479.80 28225 342.34 325.22 374.00 28107 496.07 471.27 541.96 # 28225 241.91 229.81 264.28 # 28107 361.17 343.11 394.58 28226 410.93 390.38 448.94 28108 376.52 357.69 411.34 # 28226 301.88 286.79 329.81 # 28108 273.47 259.80 298.77 28230 377.88 358.99 412.84 28110 395.91 376.11 432.53 # 28230 277.45 263.58 303.12 # 28110 273.00 259.35 298.25 28232 336.02 319.22 367.10 28111 449.60 427.12 491.19 # 28232 236.34 224.52 258.20 # 28111 318.45 302.53 347.91 28234 348.76 331.32 381.02 28112 426.10 404.80 465.52 # 28234 247.96 235.56 270.89 # 28112 298.32 283.40 325.91 28238 600.20 570.19 655.72 28113 509.61 484.13 556.75 # 28238 469.79 446.30 513.25 # 28113 391.20 371.64 427.39 28240 388.70 369.27 424.66 28114 922.80 876.66 1,008.16 # 28240 284.52 270.29 310.83 # 28114 754.55 716.82 824.34 28250 493.17 468.51 538.79 28116 658.49 625.57 719.41 # 28250 377.00 358.15 411.87 # 28116 534.08 507.38 583.49 28260 600.46 570.44 656.01 28118 511.42 485.85 558.73 # 28260 485.41 461.14 530.31 # 28118 386.63 367.30 422.40 28261 869.51 826.03 949.93 28119 455.92 433.12 498.09 # 28261 739.48 702.51 807.89 # 28119 342.01 324.91 373.65 28262 1,214.04 1,153.34 1,326.34 28120 506.66 481.33 553.53 # 28262 1,034.92 983.17 1,130.65 # 28120 368.39 349.97 402.47 28264 778.30 739.39 850.30 28122 586.90 557.56 641.19 # 28264 651.64 619.06 711.92 # 28122 472.24 448.63 515.92 28270 420.25 399.24 459.13 28124 417.96 397.06 456.62 # 28270 315.33 299.56 344.49 # 28124 316.03 300.23 345.26 28272 344.02 326.82 375.84 28126 338.63 321.70 369.96 # 28272 245.84 233.55 268.58 # 28126 237.82 225.93 259.82 28280 460.84 437.80 503.47 28130 586.87 557.53 641.16 # 28280 342.43 325.31 374.11 28140 552.55 524.92 603.66 28285 407.25 386.89 444.92 # 28140 429.26 407.80 468.97 # 28285 302.70 287.57 330.71 28150 376.99 358.14 411.86 28286 397.98 378.08 434.79 # 28150 271.32 257.75 296.41 # 28286 290.43 275.91 317.30 28153 351.86 334.27 384.41 28288 510.80 485.26 558.05 # 28153 246.94 234.59 269.78 # 28288 395.75 375.96 432.35 28160 361.08 343.03 394.48 28289 643.01 610.86 702.49 # 28160 257.65 244.77 281.49 # 28289 512.23 486.62 559.61 28171 573.03 544.38 626.04 28290 502.14 477.03 548.58 28173 657.22 624.36 718.01 # 28290 374.35 355.63 408.97 # 28173 523.44 497.27 571.86 28292 684.54 650.31 747.86 28175 483.52 459.34 528.24 # 28292 553.00 525.35 604.15 # 28175 369.97 351.47 404.19 28293 914.94 869.19 999.57 28190 216.73 205.89 236.77 # 28293 667.99 634.59 729.78 # 28190 126.04 119.74 137.70 28294 659.56 626.58 720.57 28192 413.52 392.84 451.77 # 28294 507.41 482.04 554.35 # 28192 301.48 286.41 329.37 28296 646.52 614.19 706.32 28193 473.56 449.88 517.36 # 28296 504.50 479.28 551.17 # 28193 358.14 340.23 391.26 28297 730.26 693.75 797.81 28200 413.58 392.90 451.84 # 28297 566.50 538.18 618.91 # 28200 300.79 285.75 328.61 28298 631.28 599.72 689.68 28202 547.99 520.59 598.68 # 28298 482.89 458.75 527.56 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 22 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 28299 809.11 768.65 883.95 # 28490 104.18 98.97 113.82 # 28299 652.84 620.20 713.23 28495 150.20 142.69 164.09 28300 611.34 580.77 667.89 # 28495 132.96 126.31 145.26 28302 606.33 576.01 662.41 28496 368.00 349.60 402.04 28304 699.85 664.86 764.59 # 28496 203.49 193.32 222.32 # 28304 556.70 528.87 608.20 28505 582.17 553.06 636.02 28305 641.76 609.67 701.12 # 28505 444.27 422.06 485.37 28306 526.94 500.59 575.68 28510 103.06 97.91 112.60 # 28306 377.79 358.90 412.74 # 28510 101.19 96.13 110.55 28307 622.82 591.68 680.43 28515 135.79 129.00 148.35 # 28307 426.83 405.49 466.31 # 28515 124.93 118.68 136.48 28308 477.79 453.90 521.99 28525 491.01 466.46 536.43 # 28308 347.00 329.65 379.10 # 28525 353.48 335.81 386.18 28309 823.57 782.39 899.75 28530 99.37 94.40 108.56 28310 470.12 446.61 513.60 # 28530 91.87 87.28 100.37 # 28310 337.84 320.95 369.09 28531 324.40 308.18 354.41 28312 431.22 409.66 471.11 # 28531 174.89 166.15 191.07 # 28312 301.56 286.48 329.45 28540 176.00 167.20 192.28 28313 452.10 429.50 493.93 # 28540 164.39 156.17 179.60 # 28313 345.68 328.40 377.66 28545 216.23 205.42 236.23 28315 415.05 394.30 453.45 # 28545 198.99 189.04 217.40 # 28315 307.87 292.48 336.35 28546 411.38 390.81 449.43 28320 578.16 549.25 631.64 # 28546 268.61 255.18 293.46 28322 680.85 646.81 743.83 28555 759.07 721.12 829.29 # 28322 534.33 507.61 583.75 # 28555 595.31 565.54 650.37 28340 543.33 516.16 593.58 28570 152.08 144.48 166.15 # 28340 417.05 396.20 455.63 # 28570 136.72 129.88 149.36 28341 624.91 593.66 682.71 28575 290.12 275.61 316.95 # 28341 493.01 468.36 538.61 # 28575 271.01 257.46 296.08 28344 419.89 398.90 458.74 28576 316.97 301.12 346.29 # 28344 294.35 279.63 321.57 28585 807.39 767.02 882.07 28345 504.06 478.86 550.69 # 28585 668.37 634.95 730.19 # 28345 383.02 363.87 418.45 28600 183.89 174.70 200.91 28360 888.40 843.98 970.58 # 28600 165.15 156.89 180.42 28400 212.93 202.28 232.62 28605 236.96 225.11 258.88 # 28400 195.32 185.55 213.38 # 28605 221.22 210.16 241.68 28405 345.16 327.90 377.09 28606 350.30 332.79 382.71 # 28405 323.05 306.90 352.94 28615 703.95 668.75 769.06 28406 472.98 449.33 516.73 28630 130.57 124.04 142.65 28415 1,035.69 983.91 1,131.50 # 28630 100.22 95.21 109.49 28420 1,089.74 1,035.25 1,190.54 28635 156.01 148.21 170.44 28430 199.26 189.30 217.70 # 28635 125.65 119.37 137.28 # 28430 177.16 168.30 193.55 28636 257.71 244.82 281.54 28435 280.11 266.10 306.02 # 28636 186.14 176.83 203.35 # 28435 259.13 246.17 283.10 28645 550.11 522.60 600.99 28436 380.38 361.36 415.56 # 28645 433.20 411.54 473.27 28445 975.38 926.61 1,065.60 28660 95.22 90.46 104.03 28446 1,071.08 1,017.53 1,170.16 # 28660 76.85 73.01 83.96 28450 184.42 175.20 201.48 28665 138.38 131.46 151.18 # 28450 164.93 156.68 180.18 # 28665 124.89 118.65 136.45 28455 255.10 242.35 278.70 28666 178.05 169.15 194.52 # 28455 237.86 225.97 259.87 28675 503.08 477.93 549.62 28456 245.17 232.91 267.85 # 28675 362.93 344.78 396.50 28465 558.16 530.25 609.79 28705 1,202.09 1,141.99 1,313.29 28470 183.94 174.74 200.95 28715 891.65 847.07 974.13 # 28470 165.58 157.30 180.90 28725 733.06 696.41 800.87 28475 232.49 220.87 254.00 28730 769.40 730.93 840.57 # 28475 214.50 203.78 234.35 28735 734.85 698.11 802.83 28476 303.54 288.36 331.61 28737 651.55 618.97 711.82 28485 482.87 458.73 527.54 28740 750.64 713.11 820.08 28490 119.17 113.21 130.19 # 28740 577.51 548.63 630.92 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 23 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 28750 732.16 695.55 799.88 29240 52.84 50.20 57.73 # 28750 550.42 522.90 601.34 # 29240 40.85 38.81 44.63 28755 441.41 419.34 482.24 29260 45.78 43.49 50.01 # 28755 312.87 297.23 341.81 # 29260 33.79 32.10 36.92 28760 691.06 656.51 754.99 29280 44.38 42.16 48.48 # 28760 541.91 514.81 592.03 # 29280 32.01 30.41 34.97 28800 526.75 500.41 575.47 29305 204.58 194.35 223.50 28805 694.14 659.43 758.34 # 29305 141.63 134.55 154.73 28810 406.12 385.81 443.68 29325 227.49 216.12 248.54 28820 467.95 444.55 511.23 # 29325 160.04 152.04 174.85 # 28820 321.43 305.36 351.16 29345 117.82 111.93 128.72 28825 507.49 482.12 554.44 # 29345 91.59 87.01 100.06 # 28825 367.34 348.97 401.32 29355 121.72 115.63 132.97 28890 307.51 292.13 335.95 # 29355 97.36 92.49 106.36 # 28890 208.96 198.51 228.29 29358 132.94 126.29 145.23 29000 237.12 225.26 259.05 # 29358 93.21 88.55 101.83 # 29000 153.93 146.23 168.16 29365 105.85 100.56 115.64 29010 215.57 204.79 235.51 # 29365 79.62 75.64 86.99 # 29010 141.38 134.31 154.46 29405 77.94 74.04 85.15 29015 210.00 199.50 229.43 # 29405 58.46 55.54 63.87 # 29015 145.92 138.62 159.41 29425 84.27 80.06 92.07 29020 201.06 191.01 219.66 # 29425 64.41 61.19 70.37 # 29020 130.98 124.43 143.09 29435 103.23 98.07 112.78 29025 227.30 215.94 248.33 # 29435 77.74 73.85 84.93 # 29025 159.09 151.14 173.81 29440 46.25 43.94 50.53 29035 212.03 201.43 231.64 # 29440 31.63 30.05 34.56 # 29035 126.59 120.26 138.30 29445 129.03 122.58 140.97 29040 203.36 193.19 222.17 # 29445 102.80 97.66 112.31 # 29040 140.78 133.74 153.80 29450 136.10 129.30 148.70 29044 229.19 217.73 250.39 # 29450 114.37 108.65 124.95 # 29044 147.12 139.76 160.72 29505 66.69 63.36 72.86 29046 249.81 237.32 272.92 # 29505 43.08 40.93 47.07 # 29046 168.49 160.07 184.08 29515 62.30 59.19 68.07 29049 75.49 71.72 82.48 # 29515 45.07 42.82 49.24 # 29049 54.88 52.14 59.96 29520 44.71 42.47 48.84 29055 181.24 172.18 198.01 # 29520 33.84 32.15 36.97 # 29055 121.29 115.23 132.51 29530 46.50 44.18 50.81 29058 97.30 92.44 106.31 # 29530 34.51 32.78 37.70 # 29058 74.81 71.07 81.73 29540 38.13 36.22 41.65 29065 82.22 78.11 89.83 # 29540 30.64 29.11 33.48 # 29065 60.86 57.82 66.49 29550 37.06 35.21 40.49 29075 76.40 72.58 83.47 # 29550 28.82 27.38 31.49 # 29075 55.04 52.29 60.13 29580 46.86 44.52 51.20 29085 81.30 77.24 88.83 # 29580 33.74 32.05 36.86 # 29085 59.19 56.23 64.66 29590 49.90 47.41 54.52 29086 62.50 59.38 68.29 # 29590 39.03 37.08 42.64 # 29086 43.76 41.57 47.81 29700 56.74 53.90 61.99 29105 75.35 71.58 82.32 # 29700 32.01 30.41 34.97 # 29105 53.24 50.58 58.17 29705 59.18 56.22 64.65 29125 58.79 55.85 64.23 # 29705 43.82 41.63 47.87 # 29125 38.18 36.27 41.71 29710 103.75 98.56 113.34 29126 67.54 64.16 73.78 # 29710 75.27 71.51 82.24 # 29126 46.92 44.57 51.26 29715 79.62 75.64 86.99 29130 35.52 33.74 38.80 # 29715 51.89 49.30 56.70 # 29130 26.15 24.84 28.57 29720 69.99 66.49 76.46 29131 44.32 42.10 48.42 # 29720 40.39 38.37 44.13 # 29131 29.70 28.22 32.45 29730 57.53 54.65 62.85 29200 47.34 44.97 51.72 # 29730 42.17 40.06 46.07 # 29200 36.85 35.01 40.26 29740 82.37 78.25 89.99 29220 48.86 46.42 53.38 # 29740 61.38 58.31 67.06 # 29220 38.36 36.44 41.91 29750 89.79 85.30 98.10 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 24 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 29750 70.30 66.79 76.81 # 29893 395.04 375.29 431.58 29800 464.95 441.70 507.96 29894 468.37 444.95 511.69 29804 575.46 546.69 628.69 29895 453.03 430.38 494.94 29805 420.10 399.10 458.97 29897 474.74 451.00 518.65 29806 958.96 911.01 1,047.66 29898 530.42 503.90 579.49 29807 934.30 887.59 1,020.73 29899 952.97 905.32 1,041.12 29819 526.07 499.77 574.74 29900 408.93 388.48 446.75 29820 485.47 461.20 530.38 29901 447.78 425.39 489.20 29821 530.22 503.71 579.27 29902 478.70 454.77 522.99 29822 515.18 489.42 562.83 29904 555.23 527.47 606.59 29823 563.51 535.33 615.63 29905 598.04 568.14 653.36 29824 601.08 571.03 656.68 29906 630.02 598.52 688.30 29825 525.32 499.05 573.91 29907 769.87 731.38 841.09 29826 602.18 572.07 657.88 30000 205.69 195.41 224.72 29827 982.09 932.99 1,072.94 # 30000 106.01 100.71 115.82 29828 822.05 780.95 898.09 30020 198.94 188.99 217.34 29830 405.18 384.92 442.66 # 30020 106.76 101.42 116.63 29834 441.53 419.45 482.37 30100 125.00 118.75 136.56 29835 452.95 430.30 494.85 # 30100 64.30 61.09 70.25 29836 521.13 495.07 569.33 30110 200.87 190.83 219.45 29837 474.76 451.02 518.67 # 30110 118.05 112.15 128.97 29838 530.86 504.32 579.97 30115 387.02 367.67 422.82 29840 398.48 378.56 435.34 30117 744.05 706.85 812.88 29843 428.00 406.60 467.59 # 30117 300.74 285.70 328.56 29844 443.74 421.55 484.78 30118 695.82 661.03 760.18 29845 507.97 482.57 554.96 30120 465.11 441.85 508.13 29846 466.94 443.59 510.13 # 30120 405.16 384.90 442.64 29847 485.00 460.75 529.86 30124 244.45 232.23 267.06 29848 443.24 421.08 484.24 30125 555.71 527.92 607.11 29850 512.21 486.60 559.59 30130 338.75 321.81 370.08 29851 842.55 800.42 920.48 30140 387.66 368.28 423.52 29855 706.92 671.57 772.31 30150 712.34 676.72 778.23 29856 903.75 858.56 987.34 30160 715.75 679.96 781.95 29860 583.18 554.02 637.12 30200 99.96 94.96 109.20 29861 646.17 613.86 705.94 # 30200 54.99 52.24 60.08 29862 723.18 687.02 790.07 30210 131.11 124.55 143.23 29863 716.85 681.01 783.16 # 30210 89.51 85.03 97.78 29866 940.71 893.67 1,027.72 30220 259.49 246.52 283.50 29867 1,140.24 1,083.23 1,245.71 # 30220 113.35 107.68 123.83 29868 1,519.33 1,443.36 1,659.86 30300 201.82 191.73 220.49 29870 364.84 346.60 398.59 # 30300 109.64 104.16 119.78 29871 457.89 435.00 500.25 30310 184.62 175.39 201.70 29873 458.82 435.88 501.26 30320 406.67 386.34 444.29 29874 480.67 456.64 525.14 30400 935.53 888.75 1,022.06 29875 443.16 421.00 484.15 30410 1,105.70 1,050.42 1,207.98 29876 582.40 553.28 636.27 30420 1,242.06 1,179.96 1,356.95 29877 551.35 523.78 602.35 30430 821.17 780.11 897.13 29879 589.69 560.21 644.24 30435 1,079.42 1,025.45 1,179.27 29880 615.48 584.71 672.42 30450 1,426.55 1,355.22 1,558.50 29881 573.88 545.19 626.97 30460 688.52 654.09 752.20 29882 621.02 589.97 678.47 30462 1,381.79 1,312.70 1,509.61 29883 757.42 719.55 827.48 30465 885.24 840.98 967.13 29884 549.71 522.22 600.55 30520 544.01 516.81 594.33 29885 666.50 633.18 728.16 30540 605.75 575.46 661.78 29886 562.29 534.18 614.31 30545 869.70 826.22 950.15 29887 662.66 629.53 723.96 30560 238.94 226.99 261.04 29888 896.18 851.37 979.08 # 30560 124.65 118.42 136.18 29889 1,096.35 1,041.53 1,197.76 30580 563.67 535.49 615.81 29891 625.53 594.25 683.39 # 30580 449.75 427.26 491.35 29892 638.88 606.94 697.98 30600 519.88 493.89 567.97 29893 528.82 502.38 577.74 # 30600 399.59 379.61 436.55 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 25 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 30620 555.61 527.83 607.00 31290 1,069.79 1,016.30 1,168.75 30630 562.54 534.41 614.57 31291 1,125.75 1,069.46 1,229.88 30801 200.79 190.75 219.36 31292 926.16 879.85 1,011.83 # 30801 119.48 113.51 130.54 31293 1,009.06 958.61 1,102.40 30802 258.35 245.43 282.24 31294 1,157.63 1,099.75 1,264.71 # 30802 169.54 161.06 185.22 31300 1,144.08 1,086.88 1,249.91 30901 93.81 89.12 102.49 31320 587.34 557.97 641.67 # 30901 57.46 54.59 62.78 31360 1,823.96 1,732.76 1,992.67 30903 173.50 164.83 189.55 31365 2,278.61 2,164.68 2,489.38 # 30903 74.95 71.20 81.88 31367 1,971.51 1,872.93 2,153.87 30905 215.91 205.11 235.88 31368 2,200.88 2,090.84 2,404.47 # 30905 96.37 91.55 105.28 31370 1,855.90 1,763.11 2,027.58 30906 247.96 235.56 270.89 31375 1,755.58 1,667.80 1,917.97 # 30906 126.17 119.86 137.84 31380 1,729.51 1,643.03 1,889.48 30915 521.31 495.24 569.53 31382 1,894.92 1,800.17 2,070.20 30920 750.28 712.77 819.69 31390 2,539.68 2,412.70 2,774.61 30930 109.62 104.14 119.76 31395 2,695.67 2,560.89 2,945.02 31000 159.49 151.52 174.25 31400 912.03 866.43 996.39 # 31000 94.66 89.93 103.42 31420 761.24 723.18 831.66 31002 181.53 172.45 198.32 31500 104.11 98.90 113.74 31020 431.94 410.34 471.89 31502 33.27 31.61 36.35 # 31020 316.53 300.70 345.81 31505 76.05 72.25 83.09 31030 625.56 594.28 683.42 # 31505 45.32 43.05 49.51 # 31030 470.79 447.25 514.34 31510 193.33 183.66 211.21 31032 514.67 488.94 562.28 # 31510 113.13 107.47 123.59 31040 675.80 642.01 738.31 31511 193.11 183.45 210.97 31050 445.13 422.87 486.30 # 31511 121.17 115.11 132.38 31051 581.47 552.40 635.26 31512 190.83 181.29 208.48 31070 391.85 372.26 428.10 # 31512 121.88 115.79 133.16 31075 709.02 673.57 774.61 31513 124.29 118.08 135.79 31080 913.08 867.43 997.54 31515 191.29 181.73 208.99 31081 1,109.70 1,054.22 1,212.35 # 31515 103.23 98.07 112.78 31084 1,068.19 1,014.78 1,167.00 31520 144.38 137.16 157.73 31085 1,126.06 1,069.76 1,230.22 31525 229.14 217.68 250.33 31086 1,011.19 960.63 1,104.72 # 31525 150.07 142.57 163.96 31087 998.29 948.38 1,090.64 31526 149.03 141.58 162.82 31090 903.09 857.94 986.63 31527 181.85 172.76 198.67 31200 483.78 459.59 528.53 31528 135.86 129.07 148.43 31201 660.13 627.12 721.19 31529 153.16 145.50 167.33 31205 775.88 737.09 847.65 31530 187.07 177.72 204.38 31225 1,664.73 1,581.49 1,818.71 31531 201.78 191.69 220.44 31230 1,864.83 1,771.59 2,037.33 31535 179.38 170.41 195.97 31231 172.33 163.71 188.27 31536 200.32 190.30 218.85 # 31231 71.53 67.95 78.14 31540 230.16 218.65 251.45 31233 241.22 229.16 263.53 31541 251.63 239.05 274.91 # 31233 128.42 122.00 140.30 31545 341.31 324.24 372.88 31235 276.80 262.96 302.40 31546 517.94 492.04 565.85 # 31235 153.13 145.47 167.29 31560 297.79 282.90 325.34 31237 298.01 283.11 325.58 31561 326.13 309.82 356.29 # 31237 170.60 162.07 186.38 31570 318.63 302.70 348.11 31238 306.82 291.48 335.20 # 31570 215.58 204.80 235.52 # 31238 185.41 176.14 202.56 31571 237.42 225.55 259.38 31239 605.54 575.26 661.55 31575 106.38 101.06 116.22 31240 151.72 144.13 165.75 # 31575 71.53 67.95 78.14 31254 259.16 246.20 283.13 31576 207.16 196.80 226.32 31255 381.99 362.89 417.32 # 31576 116.10 110.30 126.85 31256 187.86 178.47 205.24 31577 222.62 211.49 243.21 31267 302.03 286.93 329.97 # 31577 140.55 133.52 153.55 31276 481.43 457.36 525.96 31578 258.78 245.84 282.72 31287 220.59 209.56 240.99 # 31578 159.85 151.86 174.64 31288 255.68 242.90 279.34 31579 200.68 190.65 219.25 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 26 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 31579 132.10 125.50 144.33 31750 1,223.38 1,162.21 1,336.54 31580 1,093.91 1,039.21 1,195.09 31755 1,554.33 1,476.61 1,698.10 31582 1,738.16 1,651.25 1,898.94 31760 1,294.88 1,230.14 1,414.66 31584 1,385.05 1,315.80 1,513.17 31766 1,682.88 1,598.74 1,838.55 31587 903.25 858.09 986.80 31770 1,250.91 1,188.36 1,366.61 31588 1,029.48 978.01 1,124.71 31775 1,292.18 1,227.57 1,411.71 31590 811.19 770.63 886.22 31780 1,101.87 1,046.78 1,203.80 31595 698.27 663.36 762.86 31781 1,332.20 1,265.59 1,455.43 31600 370.11 351.60 404.34 31785 1,007.67 957.29 1,100.88 31601 246.24 233.93 269.02 31786 1,393.11 1,323.45 1,521.97 31603 208.74 198.30 228.05 31800 638.44 606.52 697.50 31605 171.40 162.83 187.25 31805 768.69 730.26 839.80 31610 645.76 613.47 705.49 31820 389.61 370.13 425.65 31611 486.86 462.52 531.90 # 31820 299.30 284.34 326.99 31612 74.25 70.54 81.12 31825 544.25 517.04 594.60 # 31612 45.02 42.77 49.19 # 31825 441.20 419.14 482.01 31613 402.95 382.80 440.22 31830 392.17 372.56 428.44 31614 668.15 634.74 729.95 # 31830 310.10 294.60 338.79 31615 169.11 160.65 184.75 32035 657.27 624.41 718.07 # 31615 119.64 113.66 130.71 32036 712.27 676.66 778.16 31620 269.30 255.84 294.22 32095 584.01 554.81 638.03 # 31620 67.32 63.95 73.54 32100 898.70 853.77 981.84 31622 300.00 285.00 327.75 32110 1,353.82 1,286.13 1,479.05 # 31622 139.24 132.28 152.12 32120 809.01 768.56 883.84 31623 329.38 312.91 359.85 32124 858.49 815.57 937.91 # 31623 141.26 134.20 154.33 32140 918.66 872.73 1,003.64 31624 305.77 290.48 334.05 32141 1,391.62 1,322.04 1,520.35 # 31624 141.64 134.56 154.74 32150 925.47 879.20 1,011.08 31625 328.79 312.35 359.20 32151 947.16 899.80 1,034.77 # 31625 164.65 156.42 179.88 32160 712.13 676.52 778.00 31628 395.62 375.84 432.22 32200 1,040.18 988.17 1,136.40 # 31628 183.90 174.71 200.92 32201 898.87 853.93 982.02 31629 609.60 579.12 665.99 # 32201 204.11 193.90 222.99 # 31629 197.02 187.17 215.25 32215 745.57 708.29 814.53 31630 195.96 186.16 214.08 32220 1,487.54 1,413.16 1,625.13 31631 221.00 209.95 241.44 32225 926.20 879.89 1,011.87 31632 71.25 67.69 77.84 32310 854.02 811.32 933.02 # 31632 49.89 47.40 54.51 32320 1,489.94 1,415.44 1,627.76 31633 86.25 81.94 94.23 32400 146.46 139.14 160.01 # 31633 63.01 59.86 68.84 # 32400 87.63 83.25 95.74 31635 336.85 320.01 368.01 32402 526.58 500.25 575.29 # 31635 182.46 173.34 199.34 32405 99.17 94.21 108.34 31636 216.09 205.29 236.08 # 32405 98.80 93.86 107.94 31637 76.39 72.57 83.46 32420 109.10 103.65 119.20 31638 243.38 231.21 265.89 32421 153.18 145.52 167.35 31640 250.30 237.79 273.46 # 32421 75.61 71.83 82.60 31641 247.97 235.57 270.91 32422 192.66 183.03 210.48 31643 170.43 161.91 186.20 # 32422 121.83 115.74 133.10 31645 294.26 279.55 321.48 32440 1,488.10 1,413.70 1,625.76 # 31645 154.86 147.12 169.19 32442 2,778.86 2,639.92 3,035.91 31646 267.56 254.18 292.31 32445 3,164.12 3,005.91 3,456.80 # 31646 134.16 127.45 146.57 32480 1,404.17 1,333.96 1,534.05 31656 307.48 292.11 335.93 32482 1,498.47 1,423.55 1,637.08 # 31656 108.49 103.07 118.53 32484 1,356.23 1,288.42 1,481.68 31715 53.57 50.89 58.52 32486 2,170.02 2,061.52 2,370.75 31717 288.64 274.21 315.34 32488 2,197.67 2,087.79 2,400.96 # 31717 106.52 101.19 116.37 32491 1,399.16 1,329.20 1,528.58 31720 50.26 47.75 54.91 32500 1,359.18 1,291.22 1,484.90 31725 90.26 85.75 98.61 32501 235.83 224.04 257.65 31730 828.02 786.62 904.61 32503 1,712.57 1,626.94 1,870.98 # 31730 138.52 131.59 151.33 32504 1,966.47 1,868.15 2,148.37 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 27 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 32540 1,569.40 1,490.93 1,714.57 33206 458.55 435.62 500.96 32550 762.21 724.10 832.72 33207 490.23 465.72 535.58 # 32550 218.85 207.91 239.10 33208 528.81 502.37 577.73 32551 168.17 159.76 183.72 33210 181.23 172.17 198.00 32560 283.67 269.49 309.91 33211 181.60 172.52 198.40 # 32560 107.18 101.82 117.09 33212 342.29 325.18 373.96 32601 294.21 279.50 321.43 33213 390.90 371.36 427.06 32602 319.03 303.08 348.54 33214 484.75 460.51 529.59 32603 413.11 392.45 451.32 33215 309.94 294.44 338.61 32604 464.17 440.96 507.10 33216 383.05 363.90 418.49 32605 366.30 347.99 400.19 33217 379.47 360.50 414.58 32606 443.22 421.06 484.22 33218 396.11 376.30 432.75 32650 632.48 600.86 690.99 33220 399.74 379.75 436.71 32651 1,000.52 950.49 1,093.06 33222 348.45 331.03 380.68 32652 1,518.99 1,443.04 1,659.50 33223 421.44 400.37 460.43 32653 969.11 920.65 1,058.75 33224 512.29 486.68 559.68 32654 1,073.89 1,020.20 1,173.23 33225 461.95 438.85 504.68 32655 884.03 839.83 965.80 33226 494.52 469.79 540.26 32656 756.59 718.76 826.57 33233 244.81 232.57 267.46 32657 745.60 708.32 814.57 33234 492.56 467.93 538.12 32658 682.71 648.57 745.86 33235 637.11 605.25 696.04 32659 694.57 659.84 758.82 33236 742.98 705.83 811.70 32660 980.12 931.11 1,070.78 33237 823.69 782.51 899.89 32661 761.83 723.74 832.30 33238 885.08 840.83 966.95 32662 852.50 809.88 931.36 33240 471.66 448.08 515.29 32663 1,314.64 1,248.91 1,436.25 33241 231.50 219.93 252.92 32664 807.63 767.25 882.34 33243 1,307.62 1,242.24 1,428.58 32665 1,139.38 1,082.41 1,244.77 33244 865.28 822.02 945.32 32800 871.99 828.39 952.65 33249 917.29 871.43 1,002.14 32810 844.12 801.91 922.20 33250 1,391.03 1,321.48 1,519.70 32815 2,506.94 2,381.59 2,738.83 33251 1,540.51 1,463.48 1,683.00 32820 1,260.10 1,197.10 1,376.67 33254 1,295.24 1,230.48 1,415.05 32851 2,435.93 2,314.13 2,661.25 33255 1,585.75 1,506.46 1,732.43 32852 2,699.23 2,564.27 2,948.91 33256 1,888.50 1,794.08 2,063.19 32853 2,905.03 2,759.78 3,173.75 33257 551.39 523.82 602.39 32854 3,169.03 3,010.58 3,462.17 33258 621.75 590.66 679.26 32855 257.29 244.43 281.09 33259 808.70 768.27 883.51 32856 310.42 294.90 339.14 33261 1,533.68 1,457.00 1,675.55 32900 1,280.76 1,216.72 1,399.23 33265 1,292.24 1,227.63 1,411.77 32905 1,261.55 1,198.47 1,378.24 33266 1,770.57 1,682.04 1,934.35 32906 1,565.42 1,487.15 1,710.22 33282 328.86 312.42 359.28 32940 1,155.99 1,098.19 1,262.92 33284 237.89 226.00 259.90 32960 132.73 126.09 145.00 33300 2,210.09 2,099.59 2,414.53 # 32960 96.01 91.21 104.89 33305 3,695.12 3,510.36 4,036.91 32997 342.51 325.38 374.19 33310 1,109.68 1,054.20 1,212.33 32998 2,766.90 2,628.56 3,022.84 33315 1,410.52 1,339.99 1,540.99 # 32998 298.92 283.97 326.57 33320 1,008.10 957.70 1,101.36 33010 120.60 114.57 131.76 33321 1,132.31 1,075.69 1,237.04 33011 117.76 111.87 128.65 33322 1,318.67 1,252.74 1,440.65 33015 513.47 487.80 560.97 33330 1,330.27 1,263.76 1,453.32 33020 820.75 779.71 896.67 33332 1,328.39 1,261.97 1,451.27 33025 756.68 718.85 826.68 33335 1,791.02 1,701.47 1,956.69 33030 1,210.64 1,150.11 1,322.63 33400 2,165.38 2,057.11 2,365.68 33031 1,351.15 1,283.59 1,476.13 33401 1,430.02 1,358.52 1,562.30 33050 936.96 890.11 1,023.63 33403 1,435.80 1,364.01 1,568.61 33120 1,476.05 1,402.25 1,612.59 33404 1,698.00 1,613.10 1,855.07 33130 1,302.03 1,236.93 1,422.47 33405 2,202.07 2,091.97 2,405.77 33140 1,488.85 1,414.41 1,626.57 33406 2,723.58 2,587.40 2,975.51 33141 141.70 134.62 154.81 33410 2,404.59 2,284.36 2,627.01 33202 739.23 702.27 807.61 33411 3,142.57 2,985.44 3,433.26 33203 782.65 743.52 855.05 33412 2,372.74 2,254.10 2,592.22 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 28 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 33413 3,090.83 2,936.29 3,376.73 33615 1,923.45 1,827.28 2,101.37 33414 2,065.42 1,962.15 2,256.47 33617 2,053.32 1,950.65 2,243.25 33415 1,913.57 1,817.89 2,090.57 33619 2,517.76 2,391.87 2,750.65 33416 1,920.68 1,824.65 2,098.35 33641 1,535.61 1,458.83 1,677.65 33417 1,601.54 1,521.46 1,749.68 33645 1,509.98 1,434.48 1,649.65 33420 1,308.40 1,242.98 1,429.43 33647 1,613.36 1,532.69 1,762.59 33422 1,608.74 1,528.30 1,757.55 33660 1,678.98 1,595.03 1,834.28 33425 2,517.80 2,391.91 2,750.70 33665 1,823.20 1,732.04 1,991.85 33426 2,277.51 2,163.63 2,488.17 33670 1,890.69 1,796.16 2,065.58 33427 2,370.18 2,251.67 2,589.42 33675 1,885.83 1,791.54 2,060.27 33430 2,638.97 2,507.02 2,883.07 33676 1,961.53 1,863.45 2,142.97 33460 2,241.24 2,129.18 2,448.56 33677 2,038.37 1,936.45 2,226.92 33463 2,834.97 2,693.22 3,097.20 33681 1,747.81 1,660.42 1,909.48 33464 2,277.82 2,163.93 2,488.52 33684 1,790.11 1,700.60 1,955.69 33465 2,550.17 2,422.66 2,786.06 33688 1,785.67 1,696.39 1,950.85 33468 1,795.63 1,705.85 1,961.73 33690 1,108.37 1,052.95 1,210.89 33470 1,145.85 1,088.56 1,251.84 33692 1,683.25 1,599.09 1,838.95 33471 1,260.99 1,197.94 1,377.63 33694 1,894.48 1,799.76 2,069.72 33472 1,272.55 1,208.92 1,390.26 33697 2,056.21 1,953.40 2,246.41 33474 1,963.89 1,865.70 2,145.56 33702 1,462.91 1,389.76 1,598.22 33475 2,204.75 2,094.51 2,408.69 33710 1,777.85 1,688.96 1,942.30 33476 1,402.05 1,331.95 1,531.74 33720 1,482.41 1,408.29 1,619.53 33478 1,499.00 1,424.05 1,637.66 33722 1,491.72 1,417.13 1,629.70 33496 1,602.78 1,522.64 1,751.04 33724 1,503.59 1,428.41 1,642.67 33500 1,504.05 1,428.85 1,643.18 33726 1,963.08 1,864.93 2,144.67 33501 1,050.00 997.50 1,147.13 33730 1,866.73 1,773.39 2,039.40 33502 1,208.13 1,147.72 1,319.88 33732 1,566.20 1,487.89 1,711.07 33503 1,308.74 1,243.30 1,429.80 33735 1,200.13 1,140.12 1,311.14 33504 1,378.80 1,309.86 1,506.34 33736 1,331.31 1,264.74 1,454.45 33505 1,909.42 1,813.95 2,086.04 33737 1,239.11 1,177.15 1,353.72 33506 1,963.34 1,865.17 2,144.95 33750 1,267.26 1,203.90 1,384.49 33507 1,661.13 1,578.07 1,814.78 33755 1,230.89 1,169.35 1,344.75 33508 15.59 14.81 17.03 33762 1,229.64 1,168.16 1,343.38 33510 1,874.11 1,780.40 2,047.46 33764 1,211.36 1,150.79 1,323.41 33511 2,047.10 1,944.75 2,236.46 33766 1,334.29 1,267.58 1,457.72 33512 2,307.97 2,192.57 2,521.46 33767 1,344.72 1,277.48 1,469.10 33513 2,355.60 2,237.82 2,573.49 33768 408.79 388.35 446.60 33514 2,499.85 2,374.86 2,731.09 33770 2,042.95 1,940.80 2,231.92 33516 2,598.30 2,468.39 2,838.65 33771 2,094.09 1,989.39 2,287.80 33517 177.92 169.02 194.37 33774 1,726.57 1,640.24 1,886.28 33518 385.86 366.57 421.56 33775 1,796.34 1,706.52 1,962.50 33519 514.46 488.74 562.05 33776 1,891.54 1,796.96 2,066.50 33521 621.93 590.83 679.45 33777 1,848.06 1,755.66 2,019.01 33522 706.02 670.72 771.33 33778 2,272.64 2,159.01 2,482.86 33523 805.06 764.81 879.53 33779 2,200.00 2,090.00 2,403.50 33530 490.94 466.39 536.35 33780 2,284.38 2,170.16 2,495.68 33533 1,823.63 1,732.45 1,992.32 33781 2,225.33 2,114.06 2,431.17 33534 2,123.87 2,017.68 2,320.33 33786 2,191.52 2,081.94 2,394.23 33535 2,358.60 2,240.67 2,576.77 33788 1,480.52 1,406.49 1,617.46 33536 2,525.51 2,399.23 2,759.11 33800 928.85 882.41 1,014.77 33542 2,437.36 2,315.49 2,662.81 33802 1,002.96 952.81 1,095.73 33545 2,874.93 2,731.18 3,140.86 33803 1,083.93 1,029.73 1,184.19 33548 2,821.86 2,680.77 3,082.89 33813 1,238.30 1,176.39 1,352.85 33572 224.93 213.68 245.73 33814 1,453.98 1,381.28 1,588.47 33600 1,629.47 1,548.00 1,780.20 33820 932.76 886.12 1,019.04 33602 1,554.51 1,476.78 1,698.30 33822 988.91 939.46 1,080.38 33606 1,692.42 1,607.80 1,848.97 33824 1,118.97 1,063.02 1,222.47 33608 1,737.15 1,650.29 1,897.83 33840 1,135.23 1,078.47 1,240.24 33610 1,694.73 1,609.99 1,851.49 33845 1,308.46 1,243.04 1,429.50 33611 1,865.45 1,772.18 2,038.01 33851 1,198.54 1,138.61 1,309.40 33612 1,920.01 1,824.01 2,097.61 33852 1,311.53 1,245.95 1,432.84 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 29 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 33853 1,799.38 1,709.41 1,965.82 34803 1,258.92 1,195.97 1,375.37 33860 3,005.51 2,855.23 3,283.51 34804 1,227.72 1,166.33 1,341.28 33861 2,330.95 2,214.40 2,546.56 34805 1,153.64 1,095.96 1,260.35 33863 2,997.35 2,847.48 3,274.60 34806 103.28 98.12 112.84 33864 3,081.81 2,927.72 3,366.88 34808 203.02 192.87 221.80 33870 2,433.12 2,311.46 2,658.18 34812 334.32 317.60 365.24 33875 1,890.34 1,795.82 2,065.19 34813 233.39 221.72 254.98 33877 3,372.10 3,203.50 3,684.03 34820 481.58 457.50 526.13 33880 1,751.07 1,663.52 1,913.05 34825 689.20 654.74 752.95 33881 1,503.78 1,428.59 1,642.88 34826 202.77 192.63 221.52 33883 1,096.10 1,041.30 1,197.50 34830 1,786.56 1,697.23 1,951.81 33884 398.89 378.95 435.79 34831 1,891.03 1,796.48 2,065.95 33886 941.89 894.80 1,029.02 34832 1,919.60 1,823.62 2,097.16 33889 779.51 740.53 851.61 34833 600.93 570.88 656.51 33891 974.80 926.06 1,064.97 34834 272.71 259.07 297.93 33910 1,586.04 1,506.74 1,732.75 34900 891.48 846.91 973.95 33915 1,278.15 1,214.24 1,396.38 35001 1,109.67 1,054.19 1,212.32 33916 1,591.85 1,512.26 1,739.10 35002 1,170.80 1,112.26 1,279.10 33917 1,438.66 1,366.73 1,571.74 35005 1,025.91 974.61 1,120.80 33920 1,732.56 1,645.93 1,892.82 35011 972.41 923.79 1,062.36 33922 1,313.59 1,247.91 1,435.10 35013 1,206.69 1,146.36 1,318.31 33924 275.37 261.60 300.84 35021 1,186.29 1,126.98 1,296.03 33925 1,684.30 1,600.09 1,840.10 35022 1,340.34 1,273.32 1,464.32 33926 2,232.98 2,121.33 2,439.53 35045 946.05 898.75 1,033.56 33933 355.82 338.03 388.73 35081 1,696.06 1,611.26 1,852.95 33935 3,313.88 3,148.19 3,620.42 35082 2,126.79 2,020.45 2,323.52 33944 250.75 238.21 273.94 35091 1,786.67 1,697.34 1,951.94 33945 4,440.19 4,218.18 4,850.91 35092 2,539.51 2,412.53 2,774.41 33960 957.88 909.99 1,046.49 35102 1,838.69 1,746.76 2,008.77 33961 538.56 511.63 588.37 35103 2,196.26 2,086.45 2,399.42 33967 266.96 253.61 291.65 35111 1,355.05 1,287.30 1,480.40 33968 33.99 32.29 37.13 35112 1,661.06 1,578.01 1,814.71 33970 354.93 337.18 387.76 35121 1,606.59 1,526.26 1,755.20 33971 686.84 652.50 750.38 35122 1,926.30 1,829.99 2,104.49 33973 516.92 491.07 564.73 35131 1,370.13 1,301.62 1,496.86 33974 874.37 830.65 955.25 35132 1,656.85 1,574.01 1,810.11 33975 1,063.79 1,010.60 1,162.19 35141 1,087.76 1,033.37 1,188.38 33976 1,184.05 1,124.85 1,293.58 35142 1,301.99 1,236.89 1,422.42 33977 1,153.28 1,095.62 1,259.96 35151 1,226.67 1,165.34 1,340.14 33978 1,267.23 1,203.87 1,384.45 35152 1,425.55 1,354.27 1,557.41 33979 2,331.03 2,214.48 2,546.65 35180 826.71 785.37 903.18 33980 3,445.47 3,273.20 3,764.18 35182 1,676.68 1,592.85 1,831.78 34001 928.41 881.99 1,014.29 35184 987.88 938.49 1,079.26 34051 930.01 883.51 1,016.04 35188 829.49 788.02 906.22 34101 590.19 560.68 644.78 35189 1,545.49 1,468.22 1,688.45 34111 590.03 560.53 644.61 35190 724.73 688.49 791.76 34151 1,361.09 1,293.04 1,487.00 35201 908.29 862.88 992.31 34201 966.33 918.01 1,055.71 35206 742.53 705.40 811.21 34203 942.22 895.11 1,029.38 35207 676.80 642.96 739.40 34401 1,410.01 1,339.51 1,540.44 35211 1,320.30 1,254.29 1,442.43 34421 716.13 680.32 782.37 35216 1,847.78 1,755.39 2,018.70 34451 1,470.11 1,396.60 1,606.09 35221 1,356.24 1,288.43 1,481.69 34471 1,039.75 987.76 1,135.92 35226 820.17 779.16 896.03 34490 593.59 563.91 648.50 35231 1,139.33 1,082.36 1,244.71 34501 919.09 873.14 1,004.11 35236 949.09 901.64 1,036.89 34502 1,487.62 1,413.24 1,625.23 35241 1,377.61 1,308.73 1,505.04 34510 1,044.86 992.62 1,141.51 35246 1,496.67 1,421.84 1,635.12 34520 1,002.90 952.76 1,095.67 35251 1,611.04 1,530.49 1,760.06 34530 946.45 899.13 1,034.00 35256 997.05 947.20 1,089.28 34800 1,122.63 1,066.50 1,226.48 35261 1,008.85 958.41 1,102.17 34802 1,228.22 1,166.81 1,341.83 35266 836.50 794.68 913.88 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 30 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 35271 1,318.51 1,252.58 1,440.47 35511 1,161.06 1,103.01 1,268.46 35276 1,382.63 1,313.50 1,510.53 35512 1,208.87 1,148.43 1,320.69 35281 1,540.22 1,463.21 1,682.69 35515 1,299.97 1,234.97 1,420.22 35286 916.02 870.22 1,000.75 35516 1,191.48 1,131.91 1,301.70 35301 1,026.34 975.02 1,121.27 35518 1,181.16 1,122.10 1,290.42 35302 1,089.60 1,035.12 1,190.39 35521 1,242.65 1,180.52 1,357.60 35303 1,199.02 1,139.07 1,309.93 35522 1,181.06 1,122.01 1,290.31 35304 1,246.58 1,184.25 1,361.89 35523 1,252.38 1,189.76 1,368.22 35305 1,197.52 1,137.64 1,308.29 35525 1,107.42 1,052.05 1,209.86 35306 446.25 423.94 487.53 35526 1,630.94 1,549.39 1,781.80 35311 1,473.83 1,400.14 1,610.16 35531 1,981.21 1,882.15 2,164.47 35321 873.15 829.49 953.91 35533 1,536.17 1,459.36 1,678.26 35331 1,439.97 1,367.97 1,573.17 35535 1,966.56 1,868.23 2,148.46 35341 1,353.57 1,285.89 1,478.77 35536 1,707.02 1,621.67 1,864.92 35351 1,259.06 1,196.11 1,375.53 35537 2,117.10 2,011.25 2,312.94 35355 1,023.20 972.04 1,117.85 35538 2,376.70 2,257.87 2,596.55 35361 1,549.71 1,472.22 1,693.05 35539 2,201.78 2,091.69 2,405.44 35363 1,690.26 1,605.75 1,846.61 35540 2,466.45 2,343.13 2,694.60 35371 806.79 766.45 881.42 35548 1,178.83 1,119.89 1,287.87 35372 967.37 919.00 1,056.85 35549 1,280.97 1,216.92 1,399.46 35390 157.57 149.69 172.14 35551 1,459.84 1,386.85 1,594.88 35400 149.09 141.64 162.89 35556 1,357.63 1,289.75 1,483.21 35450 506.58 481.25 553.44 35558 1,201.41 1,141.34 1,312.54 35452 351.09 333.54 383.57 35560 1,743.61 1,656.43 1,904.89 35454 307.67 292.29 336.13 35563 1,337.40 1,270.53 1,461.11 35456 372.37 353.75 406.81 35565 1,296.91 1,232.06 1,416.87 35458 478.32 454.40 522.56 35566 1,627.60 1,546.22 1,778.15 35459 438.98 417.03 479.58 35570 1,521.41 1,445.34 1,662.14 35460 305.13 289.87 333.35 35571 1,315.01 1,249.26 1,436.65 35470 2,828.97 2,687.52 3,090.65 35572 341.93 324.83 373.55 # 35470 454.67 431.94 496.73 35583 1,401.98 1,331.88 1,531.66 35471 3,108.80 2,953.36 3,396.36 35585 1,639.38 1,557.41 1,791.02 # 35471 545.26 518.00 595.70 35587 1,356.39 1,288.57 1,481.86 35472 2,155.42 2,047.65 2,354.80 35600 251.79 239.20 275.08 # 35472 363.07 344.92 396.66 35601 1,412.78 1,342.14 1,543.46 35473 2,059.54 1,956.56 2,250.04 35606 1,151.97 1,094.37 1,258.53 # 35473 321.54 305.46 351.28 35612 903.56 858.38 987.14 35474 2,749.32 2,611.85 3,003.63 35616 1,105.17 1,049.91 1,207.40 # 35474 388.88 369.44 424.86 35621 1,085.67 1,031.39 1,186.10 35475 2,215.03 2,104.28 2,419.92 35623 1,333.31 1,266.64 1,456.64 # 35475 487.15 462.79 532.21 35626 1,531.28 1,454.72 1,672.93 35476 1,675.98 1,592.18 1,831.01 35631 1,821.12 1,730.06 1,989.57 # 35476 311.58 296.00 340.40 35632 1,867.24 1,773.88 2,039.96 35480 549.88 522.39 600.75 35633 2,015.82 1,915.03 2,202.28 35481 395.24 375.48 431.80 35634 1,827.56 1,736.18 1,996.61 35482 346.50 329.18 378.56 35636 1,619.82 1,538.83 1,769.65 35483 417.36 396.49 455.96 35637 1,673.50 1,589.83 1,828.30 35484 520.64 494.61 568.80 35638 1,710.41 1,624.89 1,868.62 35485 483.57 459.39 528.30 35642 1,019.13 968.17 1,113.40 35490 608.96 578.51 665.29 35645 962.06 913.96 1,051.05 35491 405.98 385.68 443.53 35646 1,689.73 1,605.24 1,846.03 35492 370.68 352.15 404.97 35647 1,530.12 1,453.61 1,671.65 35493 451.38 428.81 493.13 35650 1,046.84 994.50 1,143.68 35494 573.01 544.36 626.01 35651 1,356.88 1,289.04 1,482.40 35495 522.41 496.29 570.73 35654 1,350.43 1,282.91 1,475.35 35500 315.22 299.46 344.38 35656 1,064.60 1,011.37 1,163.08 35501 1,528.34 1,451.92 1,669.71 35661 1,066.88 1,013.54 1,165.57 35506 1,304.41 1,239.19 1,425.07 35663 1,236.60 1,174.77 1,350.99 35508 1,349.43 1,281.96 1,474.25 35665 1,157.71 1,099.82 1,264.79 35509 1,469.04 1,395.59 1,604.93 35666 1,250.18 1,187.67 1,365.82 35510 1,240.77 1,178.73 1,355.54 35671 1,101.76 1,046.67 1,203.67 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 31 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 35681 78.78 74.84 86.07 # 36215 243.38 231.21 265.89 35682 351.43 333.86 383.94 36216 1,245.24 1,182.98 1,360.43 35683 414.64 393.91 453.00 # 36216 274.30 260.59 299.68 35685 197.34 187.47 215.59 36217 2,032.90 1,931.26 2,220.95 35686 165.39 157.12 180.69 # 36217 327.87 311.48 358.20 35691 969.58 921.10 1,059.27 36218 190.48 180.96 208.10 35693 861.89 818.80 941.62 # 36218 52.21 49.60 57.04 35694 1,001.67 951.59 1,094.33 36245 1,257.70 1,194.82 1,374.04 35695 1,043.96 991.76 1,140.52 # 36245 250.79 238.25 273.99 35697 147.26 139.90 160.89 36246 1,234.04 1,172.34 1,348.19 35700 151.39 143.82 165.39 # 36246 272.85 259.21 298.09 35701 523.35 497.18 571.76 36247 1,941.59 1,844.51 2,121.19 35721 444.08 421.88 485.16 # 36247 324.63 308.40 354.66 35741 485.83 461.54 530.77 36248 163.50 155.33 178.63 35761 360.65 342.62 394.01 # 36248 52.21 49.60 57.04 35800 462.89 439.75 505.71 36260 554.79 527.05 606.11 35820 1,817.28 1,726.42 1,985.38 36261 339.62 322.64 371.04 35840 603.24 573.08 659.04 36262 258.87 245.93 282.82 35860 391.39 371.82 427.59 36400 24.70 23.47 26.99 35870 1,256.96 1,194.11 1,373.23 # 36400 17.20 16.34 18.79 35875 580.37 551.35 634.05 36405 22.55 21.42 24.63 35876 926.76 880.42 1,012.48 # 36405 15.05 14.30 16.45 35879 907.80 862.41 991.77 36406 16.40 15.58 17.92 35881 1,009.04 958.59 1,102.38 # 36406 8.91 8.46 9.73 35883 1,173.38 1,114.71 1,281.92 36410 18.28 17.37 19.98 35884 1,236.77 1,174.93 1,351.17 # 36410 8.53 8.10 9.32 35901 488.70 464.27 533.91 36420 46.96 44.61 51.30 35903 552.49 524.87 603.60 36425 37.03 35.18 40.46 35905 1,706.57 1,621.24 1,864.43 36430 36.22 34.41 39.57 35907 1,879.04 1,785.09 2,052.85 36440 49.31 46.84 53.87 36000 24.65 23.42 26.93 36450 113.91 108.21 124.44 # 36000 9.28 8.82 10.14 36455 124.99 118.74 136.55 36002 164.58 156.35 179.80 36460 322.43 306.31 352.26 # 36002 108.37 102.95 118.39 36470 132.37 125.75 144.61 36005 337.13 320.27 368.31 # 36470 66.42 63.10 72.57 # 36005 48.96 46.51 53.49 36471 162.42 154.30 177.45 36010 580.00 551.00 633.65 # 36471 93.10 88.45 101.72 # 36010 122.45 116.33 133.78 36475 1,747.84 1,660.45 1,909.52 36011 919.67 873.69 1,004.74 # 36475 330.97 314.42 361.58 # 36011 158.22 150.31 172.86 36476 371.10 352.55 405.43 36012 864.15 820.94 944.08 # 36476 161.63 153.55 176.58 # 36012 179.14 170.18 195.71 36478 1,437.93 1,366.03 1,570.93 36013 799.17 759.21 873.09 # 36478 334.35 317.63 365.27 # 36013 128.03 121.63 139.87 36479 390.59 371.06 426.72 36014 833.82 792.13 910.95 # 36479 162.75 154.61 177.80 # 36014 155.93 148.13 170.35 36481 404.43 384.21 441.84 36015 914.03 868.33 998.58 36500 179.39 170.42 195.98 # 36015 180.31 171.29 196.98 36510 105.81 100.52 115.60 36100 527.33 500.96 576.10 # 36510 55.22 52.46 60.33 # 36100 157.47 149.60 172.04 36511 87.32 82.95 95.39 36120 437.57 415.69 478.04 36512 88.82 84.38 97.04 # 36120 99.18 94.22 108.35 36513 91.07 86.52 99.50 36140 483.62 459.44 528.36 36514 510.39 484.87 557.60 # 36140 102.14 97.03 111.58 # 36514 86.57 82.24 94.58 36145 479.41 455.44 523.76 36515 1,913.39 1,817.72 2,090.38 # 36145 100.18 95.17 109.45 # 36515 84.70 80.47 92.54 36160 531.03 504.48 580.15 36516 2,167.44 2,059.07 2,367.93 # 36160 132.69 126.06 144.97 # 36516 60.70 57.67 66.32 36200 645.79 613.50 705.53 36522 1,349.60 1,282.12 1,474.44 # 36200 152.64 145.01 166.76 # 36522 98.75 93.81 107.88 36215 1,139.74 1,082.75 1,245.16 36555 266.75 253.41 291.42 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 32 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 36555 123.60 117.42 135.03 36625 101.42 96.35 110.80 36556 226.36 215.04 247.30 36640 115.21 109.45 125.87 # 36556 116.57 110.74 127.35 36660 64.44 61.22 70.40 36557 822.22 781.11 898.28 36680 57.10 54.25 62.39 # 36557 289.73 275.24 316.53 36800 152.51 144.88 166.61 36558 795.66 755.88 869.26 36810 201.66 191.58 220.32 # 36558 277.04 263.19 302.67 36815 142.67 135.54 155.87 36560 1,132.01 1,075.41 1,236.72 36818 646.47 614.15 706.27 # 36560 343.20 326.04 374.95 36819 762.63 724.50 833.18 36561 1,120.37 1,064.35 1,224.00 36820 765.46 727.19 836.27 # 36561 331.93 315.33 362.63 36821 639.16 607.20 698.28 36563 1,130.21 1,073.70 1,234.76 36822 361.41 343.34 394.84 # 36563 342.52 325.39 374.20 36823 1,220.07 1,159.07 1,332.93 36565 945.37 898.10 1,032.82 36825 554.04 526.34 605.29 # 36565 326.69 310.36 356.91 36830 631.34 599.77 689.74 36566 3,566.67 3,388.34 3,896.59 36831 437.09 415.24 477.53 # 36566 349.97 332.47 382.34 36832 557.08 529.23 608.61 36568 304.91 289.66 333.11 36833 628.99 597.54 687.17 # 36568 95.06 90.31 103.86 36834 592.16 562.55 646.93 36569 264.04 250.84 288.47 36835 439.82 417.83 480.50 # 36569 94.66 89.93 103.42 36838 1,122.79 1,066.65 1,226.65 36570 1,152.80 1,095.16 1,259.43 36860 185.62 176.34 202.79 # 36570 306.66 291.33 335.03 # 36860 99.81 94.82 109.04 36571 1,196.30 1,136.49 1,306.96 36861 145.23 137.97 158.67 # 36571 297.69 282.81 325.23 36870 1,825.88 1,734.59 1,994.78 36575 157.15 149.29 171.68 # 36870 301.47 286.40 329.36 # 36575 36.87 35.03 40.28 37140 1,294.90 1,230.16 1,414.68 36576 349.40 331.93 381.72 37145 1,390.58 1,321.05 1,519.21 # 36576 181.89 172.80 198.72 37160 1,208.35 1,147.93 1,320.12 36578 491.00 466.45 536.42 37180 1,351.61 1,284.03 1,476.63 # 36578 208.83 198.39 228.15 37181 1,462.79 1,389.65 1,598.10 36580 226.91 215.56 247.89 37182 883.91 839.71 965.67 # 36580 67.65 64.27 73.91 37183 420.41 399.39 459.30 36581 745.15 707.89 814.07 37184 2,397.14 2,277.28 2,618.87 # 36581 197.30 187.44 215.56 # 37184 451.91 429.31 493.71 36582 1,039.47 987.50 1,135.63 37185 791.44 751.87 864.65 # 36582 290.00 275.50 316.83 # 37185 166.02 157.72 181.38 36583 1,039.77 987.78 1,135.95 37186 1,618.00 1,537.10 1,767.67 # 36583 290.31 275.79 317.16 # 37186 255.48 242.71 279.12 36584 223.69 212.51 244.39 37187 2,297.68 2,182.80 2,510.22 # 36584 70.05 66.55 76.53 # 37187 419.90 398.91 458.75 36585 1,068.51 1,015.08 1,167.34 37188 1,955.36 1,857.59 2,136.23 # 36585 272.58 258.95 297.79 # 37188 304.29 289.08 332.44 36589 160.44 152.42 175.28 37195 336.10 319.30 367.20 # 36589 134.96 128.21 147.44 37200 234.55 222.82 256.24 36590 261.23 248.17 285.40 37201 278.40 264.48 304.15 # 36590 190.03 180.53 207.61 37202 335.32 318.55 366.33 36591 22.65 21.52 24.75 37203 1,328.82 1,262.38 1,451.74 36592 24.90 23.66 27.21 # 37203 267.20 253.84 291.92 36593 32.77 31.13 35.80 37204 928.15 881.74 1,014.00 36595 599.52 569.54 654.97 37205 3,304.63 3,139.40 3,610.31 # 36595 189.56 180.08 207.09 # 37205 437.93 416.03 478.43 36596 134.68 127.95 147.14 37206 1,976.46 1,877.64 2,159.29 # 36596 45.12 42.86 49.29 # 37206 212.97 202.32 232.67 36597 125.37 119.10 136.97 37207 418.94 397.99 457.69 # 36597 63.17 60.01 69.01 37208 202.27 192.16 220.98 36598 113.34 107.67 123.82 37209 114.72 108.98 125.33 # 36598 60.50 57.48 66.10 37210 3,503.70 3,328.52 3,827.80 36600 29.86 28.37 32.63 # 37210 556.06 528.26 607.50 # 36600 14.87 14.13 16.25 37215 1,094.21 1,039.50 1,195.43 36620 49.01 46.56 53.54 37250 108.47 103.05 118.51 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 33 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 37251 80.36 76.34 87.79 38550 425.28 404.02 464.62 37500 661.46 628.39 722.65 38555 883.39 839.22 965.10 37565 657.73 624.84 718.57 38562 635.68 603.90 694.49 37600 672.04 638.44 734.21 38564 628.54 597.11 686.68 37605 765.65 727.37 836.48 38570 512.04 486.44 559.41 37606 501.00 475.95 547.34 38571 810.53 770.00 885.50 37607 358.08 340.18 391.21 38572 883.11 838.95 964.79 37609 274.93 261.18 300.36 38700 717.77 681.88 784.16 # 37609 185.74 176.45 202.92 38720 1,190.46 1,130.94 1,300.58 37615 446.78 424.44 488.11 38724 1,290.91 1,226.36 1,410.31 37616 1,030.78 979.24 1,126.13 38740 595.08 565.33 650.13 37617 1,222.57 1,161.44 1,335.66 38745 756.17 718.36 826.11 37618 356.54 338.71 389.52 38746 246.84 234.50 269.68 37620 646.16 613.85 705.93 38747 240.63 228.60 262.89 37650 485.41 461.14 530.31 38760 746.03 708.73 815.04 37660 1,147.20 1,089.84 1,253.32 38765 1,159.62 1,101.64 1,266.89 37700 238.87 226.93 260.97 38770 781.61 742.53 853.91 37718 397.50 377.63 434.27 38780 983.34 934.17 1,074.30 37722 454.14 431.43 496.14 38790 77.17 73.31 84.31 37735 601.16 571.10 656.77 38792 37.74 35.85 41.23 37760 592.04 562.44 646.81 38794 295.40 280.63 322.72 37765 430.46 408.94 470.28 39000 455.47 432.70 497.61 37766 523.64 497.46 572.08 39010 750.98 713.43 820.44 37780 246.59 234.26 269.40 39200 830.34 788.82 907.14 37785 334.44 317.72 365.38 39220 1,070.35 1,016.83 1,169.35 # 37785 247.13 234.77 269.99 39400 469.33 445.86 512.74 37788 1,321.07 1,255.02 1,443.27 39501 761.46 723.39 831.90 37790 481.09 457.04 525.60 39502 912.23 866.62 996.61 38100 993.90 944.21 1,085.84 39503 5,309.70 5,044.22 5,800.85 38101 998.31 948.39 1,090.65 39520 911.79 866.20 996.13 38102 236.09 224.29 257.93 39530 872.35 828.73 953.04 38115 1,105.50 1,050.23 1,207.76 39531 910.61 865.08 994.84 38120 919.72 873.73 1,004.79 39540 777.41 738.54 849.32 38200 134.27 127.56 146.69 39541 838.65 796.72 916.23 38205 77.75 73.86 84.94 39545 828.94 787.49 905.61 38206 77.75 73.86 84.94 39560 714.99 679.24 781.13 38220 150.33 142.81 164.23 39561 1,113.26 1,057.60 1,216.24 # 38220 58.52 55.59 63.93 40490 118.66 112.73 129.64 38221 166.37 158.05 181.76 # 40490 68.07 64.67 74.37 # 38221 74.19 70.48 81.05 40500 447.27 424.91 488.65 38230 299.16 284.20 326.83 # 40500 326.60 310.27 356.81 38240 120.47 114.45 131.62 40510 431.32 409.75 471.21 38241 121.22 115.16 132.43 # 40510 321.52 305.44 351.26 38242 91.86 87.27 100.36 40520 443.47 421.30 484.50 38300 245.66 233.38 268.39 # 40520 325.06 308.81 355.13 # 38300 163.59 155.41 178.72 40525 504.10 478.90 550.74 38305 411.28 390.72 449.33 40527 595.30 565.54 650.37 38308 393.67 373.99 430.09 40530 489.02 464.57 534.26 38380 510.98 485.43 558.24 # 40530 368.74 350.30 402.85 38381 753.31 715.64 822.99 40650 369.13 350.67 403.27 38382 610.24 579.73 666.69 # 40650 259.33 246.36 283.31 38500 283.92 269.72 310.18 40652 433.90 412.21 474.04 # 38500 221.72 210.63 242.22 # 40652 316.24 300.43 345.49 38505 121.31 115.24 132.53 40654 511.33 485.76 558.62 # 38505 71.47 67.90 78.09 # 40654 383.92 364.72 419.43 38510 458.64 435.71 501.07 40700 845.32 803.05 923.51 # 38510 376.19 357.38 410.99 40701 1,046.04 993.74 1,142.80 38520 411.93 391.33 450.03 40702 810.10 769.60 885.04 38525 372.76 354.12 407.24 40720 892.03 847.43 974.54 38530 478.46 454.54 522.72 40761 966.20 917.89 1,055.57 38542 461.38 438.31 504.06 40800 179.99 170.99 196.64 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 34 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 40800 114.79 109.05 125.41 41019 460.94 437.89 503.57 40801 273.98 260.28 299.32 41100 150.44 142.92 164.36 # 40801 197.91 188.01 216.21 # 41100 99.47 94.50 108.68 40804 183.68 174.50 200.68 41105 150.78 143.24 164.73 # 40804 116.23 110.42 126.98 # 41105 100.94 95.89 110.27 40805 287.04 272.69 313.59 41108 129.82 123.33 141.83 # 40805 204.97 194.72 223.93 # 41108 81.48 77.41 89.02 40806 96.16 91.35 105.05 41110 187.01 177.66 204.31 # 40806 30.96 29.41 33.82 # 41110 119.18 113.22 130.20 40808 162.17 154.06 177.17 41112 293.81 279.12 320.99 # 40808 96.59 91.76 105.52 # 41112 226.36 215.04 247.30 40810 179.79 170.80 196.42 41113 321.52 305.44 351.26 # 40810 114.21 108.50 124.78 # 41113 251.07 238.52 274.30 40812 251.33 238.76 274.57 41114 578.29 549.38 631.79 # 40812 176.39 167.57 192.71 41115 217.49 206.62 237.61 40814 337.36 320.49 368.56 # 41115 134.30 127.59 146.73 # 40814 272.91 259.26 298.15 41116 288.53 274.10 315.22 40816 355.58 337.80 388.47 # 41116 198.22 188.31 216.56 # 40816 285.51 271.23 311.91 41120 956.01 908.21 1,044.44 40818 314.82 299.08 343.94 41130 1,176.71 1,117.87 1,285.55 # 40818 246.25 233.94 269.03 41135 1,952.38 1,854.76 2,132.97 40819 269.32 255.85 294.23 41140 2,008.49 1,908.07 2,194.28 # 40819 210.11 199.60 229.54 41145 2,514.93 2,389.18 2,747.56 40820 235.71 223.92 257.51 41150 1,989.79 1,890.30 2,173.85 # 40820 155.52 147.74 169.90 41153 2,156.38 2,048.56 2,355.84 40830 215.38 204.61 235.30 41155 2,677.85 2,543.96 2,925.55 # 40830 143.06 135.91 156.30 41250 202.64 192.51 221.39 40831 285.15 270.89 311.52 # 41250 127.69 121.31 139.51 # 40831 200.84 190.80 219.42 41251 208.80 198.36 228.11 40840 723.28 687.12 790.19 # 41251 148.46 141.04 162.20 # 40840 573.39 544.72 626.43 41252 273.81 260.12 299.14 40842 711.66 676.08 777.49 # 41252 192.11 182.50 209.88 # 40842 560.65 532.62 612.51 41500 406.70 386.37 444.33 40843 927.25 880.89 1,013.02 41510 373.96 355.26 408.55 # 40843 726.77 690.43 793.99 41512 567.97 539.57 620.51 40844 1,229.02 1,167.57 1,342.71 41520 307.88 292.49 336.36 # 40844 1,018.05 967.15 1,112.22 # 41520 229.56 218.08 250.79 40845 1,336.51 1,269.68 1,460.13 41530 2,903.18 2,758.02 3,171.72 # 40845 1,141.27 1,084.21 1,246.84 # 41530 371.86 353.27 406.26 41000 142.54 135.41 155.72 41800 203.03 192.88 221.81 # 41000 100.57 95.54 109.87 # 41800 116.46 110.64 127.24 41005 201.43 191.36 220.06 41805 209.47 199.00 228.85 # 41005 115.24 109.48 125.90 # 41805 148.76 141.32 162.52 41006 320.12 304.11 349.73 41806 303.23 288.07 331.28 # 41006 233.93 222.23 255.56 # 41806 229.04 217.59 250.23 41007 321.52 305.44 351.26 41822 254.43 241.71 277.97 # 41007 227.46 216.09 248.50 # 41822 157.75 149.86 172.34 41008 329.73 313.24 360.23 41823 378.58 359.65 413.60 # 41008 242.04 229.94 264.43 # 41823 286.77 272.43 313.29 41009 350.10 332.60 382.49 41825 183.09 173.94 200.03 # 41009 262.79 249.65 287.10 # 41825 114.14 108.43 124.69 41010 181.39 172.32 198.17 41826 255.76 242.97 279.42 # 41010 99.33 94.36 108.51 # 41826 183.06 173.91 200.00 41015 376.77 357.93 411.62 41827 379.83 360.84 414.97 # 41015 302.57 287.44 330.56 # 41827 271.91 258.31 297.06 41016 386.40 367.08 422.14 41828 269.39 255.92 294.31 # 41016 313.70 298.02 342.72 # 41828 194.82 185.08 212.84 41017 389.40 369.93 425.42 41830 342.08 324.98 373.73 # 41017 315.20 299.44 344.36 # 41830 251.02 238.47 274.24 41018 444.79 422.55 485.93 41872 322.44 306.32 352.27 # 41018 367.59 349.21 401.59 # 41872 234.75 223.01 256.46 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 35 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 41874 325.74 309.45 355.87 42425 777.09 738.24 848.98 # 41874 228.68 217.25 249.84 42426 1,260.18 1,197.17 1,376.75 42000 140.77 133.73 153.79 42440 429.73 408.24 469.48 # 42000 93.17 88.51 101.79 42450 408.15 387.74 445.90 42100 133.33 126.66 145.66 # 42450 328.71 312.27 359.11 # 42100 98.85 93.91 108.00 42500 389.32 369.85 425.33 42104 186.20 176.89 203.42 # 42500 312.88 297.24 341.83 # 42104 124.37 118.15 135.87 42505 504.04 478.84 550.67 42106 235.77 223.98 257.58 # 42505 417.85 396.96 456.50 # 42106 162.69 154.56 177.74 42507 472.41 448.79 516.11 42107 407.99 387.59 445.73 42508 668.39 634.97 730.22 # 42107 312.81 297.17 341.75 42509 765.44 727.17 836.25 42120 887.82 843.43 969.94 42510 580.21 551.20 633.88 42140 223.56 212.38 244.24 42550 140.68 133.65 153.70 # 42140 140.74 133.70 153.76 # 42550 63.86 60.67 69.77 42145 641.07 609.02 700.37 42600 438.02 416.12 478.54 42160 215.37 204.60 235.29 # 42600 325.22 308.96 355.30 # 42160 138.92 131.97 151.77 42650 75.03 71.28 81.97 42180 217.30 206.44 237.41 # 42650 54.42 51.70 59.46 # 42180 167.83 159.44 183.36 42660 96.22 91.41 105.12 42182 295.80 281.01 323.16 # 42660 72.23 68.62 78.91 # 42182 243.72 231.53 266.26 42665 278.27 264.36 304.01 42200 808.63 768.20 883.43 # 42665 189.83 180.34 207.39 42205 859.38 816.41 938.87 42700 169.24 160.78 184.90 42210 967.38 919.01 1,056.86 # 42700 124.27 118.06 135.77 42215 637.39 605.52 696.35 42720 416.66 395.83 455.20 42220 497.24 472.38 543.24 # 42720 364.94 346.69 398.69 42225 863.00 819.85 942.83 42725 745.48 708.21 814.44 42226 854.57 811.84 933.62 42800 141.87 134.78 155.00 42227 831.06 789.51 907.94 # 42800 102.53 97.40 112.01 42235 679.50 645.53 742.36 42802 217.90 207.01 238.06 42260 751.38 713.81 820.88 # 42802 124.97 118.72 136.53 # 42260 620.97 589.92 678.41 42804 182.01 172.91 198.85 42280 140.37 133.35 153.35 # 42804 105.94 100.64 115.74 # 42280 94.28 89.57 103.01 42806 204.89 194.65 223.85 42281 182.21 173.10 199.07 # 42806 123.95 117.75 135.41 # 42281 138.74 131.80 151.57 42808 206.38 196.06 225.47 42300 186.54 177.21 203.79 # 42808 151.29 143.73 165.29 # 42300 138.95 132.00 151.80 42809 153.36 145.69 167.54 42305 394.70 374.97 431.22 # 42809 118.51 112.58 129.47 42310 144.97 137.72 158.38 42810 348.69 331.26 380.95 # 42310 113.49 107.82 123.99 # 42810 261.00 247.95 285.14 42320 224.26 213.05 245.01 42815 509.26 483.80 556.37 # 42320 162.42 154.30 177.45 42820 268.36 254.94 293.18 42330 208.75 198.31 228.06 42821 280.07 266.07 305.98 # 42330 150.67 143.14 164.61 42825 241.02 228.97 263.32 42335 333.26 316.60 364.09 42826 232.43 220.81 253.93 # 42335 236.58 224.75 258.46 42830 190.04 180.54 207.62 42340 417.55 396.67 456.17 42831 205.15 194.89 224.12 # 42340 310.38 294.86 339.09 42835 171.10 162.55 186.93 42400 99.58 94.60 108.79 42836 223.16 212.00 243.80 # 42400 54.24 51.53 59.26 42842 889.78 845.29 972.08 42405 273.94 260.24 299.28 42844 1,248.09 1,185.69 1,363.54 # 42405 209.48 199.01 228.86 42845 2,033.69 1,932.01 2,221.81 42408 408.39 387.97 446.17 42860 172.21 163.60 188.14 # 42408 300.47 285.45 328.27 42870 528.43 502.01 577.31 42409 296.90 282.06 324.37 42890 1,268.72 1,205.28 1,386.07 # 42409 204.72 194.48 223.65 42892 1,663.13 1,579.97 1,816.97 42410 569.95 541.45 622.67 42894 2,127.73 2,021.34 2,324.54 42415 1,028.66 977.23 1,123.81 42900 317.96 302.06 347.37 42420 1,178.54 1,119.61 1,287.55 42950 729.00 692.55 796.43 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 36 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 42953 898.27 853.36 981.36 43245 178.23 169.32 194.72 42955 684.95 650.70 748.31 43246 238.67 226.74 260.75 42960 155.75 147.96 170.15 43247 190.86 181.32 208.52 42961 386.97 367.62 422.76 43248 180.77 171.73 197.49 42962 478.66 454.73 522.94 43249 166.34 158.02 181.72 42970 357.76 339.87 390.85 43250 178.20 169.29 194.68 42971 421.62 400.54 460.62 43251 207.62 197.24 226.83 42972 473.03 449.38 516.79 43255 270.37 256.85 295.38 43020 483.45 459.28 528.17 43256 242.80 230.66 265.26 43030 480.57 456.54 525.02 43257 298.05 283.15 325.62 43045 1,209.53 1,149.05 1,321.41 43258 254.68 241.95 278.24 43100 573.53 544.85 626.58 43259 290.45 275.93 317.32 43101 942.22 895.11 1,029.38 43260 332.31 315.69 363.04 43107 2,330.44 2,213.92 2,546.01 43261 349.23 331.77 381.54 43108 3,946.73 3,749.39 4,311.80 43262 410.07 389.57 448.01 43112 2,488.56 2,364.13 2,718.75 43263 405.72 385.43 443.24 43113 3,946.40 3,749.08 4,311.44 43264 492.22 467.61 537.75 43116 4,501.58 4,276.50 4,917.98 43265 552.33 524.71 603.42 43117 2,276.65 2,162.82 2,487.24 43267 408.20 387.79 445.96 43118 3,245.10 3,082.85 3,545.28 43268 415.32 394.55 453.73 43121 2,576.51 2,447.68 2,814.83 43269 454.51 431.78 496.55 43122 2,300.84 2,185.80 2,513.67 43271 409.70 389.22 447.60 43123 3,967.57 3,769.19 4,334.57 43272 408.95 388.50 446.78 43124 3,393.93 3,224.23 3,707.86 43273 123.93 117.73 135.39 43130 725.86 689.57 793.01 43279 1,139.53 1,082.55 1,244.93 43135 1,349.83 1,282.34 1,474.69 43280 951.00 903.45 1,038.97 43200 200.79 190.75 219.36 43300 568.55 540.12 621.14 # 43200 97.73 92.84 106.77 43305 1,018.89 967.95 1,113.14 43201 276.49 262.67 302.07 43310 1,406.46 1,336.14 1,536.56 # 43201 122.85 116.71 134.22 43312 1,551.99 1,474.39 1,695.55 43202 264.40 251.18 288.86 43313 2,473.76 2,350.07 2,702.58 # 43202 108.14 102.73 118.14 43314 2,837.92 2,696.02 3,100.42 43204 212.93 202.28 232.62 43320 1,238.80 1,176.86 1,353.39 43205 213.70 203.02 233.47 43324 1,199.49 1,139.52 1,310.45 43215 145.78 138.49 159.26 43325 1,181.63 1,122.55 1,290.93 43216 184.70 175.47 201.79 43326 1,204.61 1,144.38 1,316.04 # 43216 135.98 129.18 148.56 43330 1,158.35 1,100.43 1,265.49 43217 352.88 335.24 385.53 43331 1,257.47 1,194.60 1,373.79 # 43217 159.89 151.90 174.69 43340 1,204.98 1,144.73 1,316.44 43219 162.32 154.20 177.33 43341 1,327.82 1,261.43 1,450.64 43220 120.17 114.16 131.28 43350 1,034.51 982.78 1,130.20 43226 134.03 127.33 146.43 43351 1,209.91 1,149.41 1,321.82 43227 199.35 189.38 217.79 43352 989.76 940.27 1,081.31 43228 212.47 201.85 232.13 43360 2,109.45 2,003.98 2,304.58 43231 181.47 172.40 198.26 43361 2,362.80 2,244.66 2,581.36 43232 249.70 237.22 272.80 43400 1,468.78 1,395.34 1,604.64 43234 261.94 248.84 286.17 43401 1,373.27 1,304.61 1,500.30 # 43234 112.80 107.16 123.23 43405 1,334.10 1,267.40 1,457.51 43235 282.73 268.59 308.88 43410 916.36 870.54 1,001.12 # 43235 138.08 131.18 150.86 43415 1,552.98 1,475.33 1,696.63 43236 352.39 334.77 384.99 43420 918.50 872.58 1,003.47 # 43236 168.02 159.62 183.56 43425 1,365.98 1,297.68 1,492.33 43237 227.53 216.15 248.57 43450 149.78 142.29 163.63 43238 282.65 268.52 308.80 # 43450 84.58 80.35 92.40 43239 327.14 310.78 357.40 43453 284.13 269.92 310.41 # 43239 163.39 155.22 178.50 # 43453 91.89 87.30 100.40 43240 379.30 360.34 414.39 43456 576.06 547.26 629.35 43241 148.25 140.84 161.97 # 43456 147.74 140.35 161.40 43242 405.15 384.89 442.62 43458 366.56 348.23 400.46 43243 255.40 242.63 279.02 # 43458 172.45 163.83 188.40 43244 283.12 268.96 309.30 43460 208.93 198.48 228.25 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 37 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 43496 2,014.97 1,914.22 2,201.35 44021 855.22 812.46 934.33 43500 681.92 647.82 744.99 44025 860.31 817.29 939.88 43501 1,170.10 1,111.60 1,278.34 44050 814.20 773.49 889.51 43502 1,323.89 1,257.70 1,446.36 44055 1,302.78 1,237.64 1,423.29 43510 847.44 805.07 925.83 44100 109.05 103.60 119.14 43520 617.33 586.46 674.43 44110 738.04 701.14 806.31 43600 101.20 96.14 110.56 44111 858.30 815.39 937.70 43605 723.25 687.09 790.15 44120 1,062.81 1,009.67 1,161.12 43610 853.35 810.68 932.28 44121 217.77 206.88 237.91 43611 1,062.34 1,009.22 1,160.60 44125 1,031.69 980.11 1,127.13 43620 1,728.19 1,641.78 1,888.05 44126 2,128.41 2,021.99 2,325.29 43621 1,969.50 1,871.03 2,151.68 44127 2,475.22 2,351.46 2,704.18 43622 1,997.11 1,897.25 2,181.84 44128 218.64 207.71 238.87 43631 1,267.88 1,204.49 1,385.16 44130 1,116.36 1,060.54 1,219.62 43632 1,731.84 1,645.25 1,892.04 44137 1,013.02 962.37 1,106.73 43633 1,647.01 1,564.66 1,799.36 44139 109.08 103.63 119.17 43634 1,819.33 1,728.36 1,987.61 44140 1,173.73 1,115.04 1,282.30 43635 100.91 95.86 110.24 44141 1,554.32 1,476.60 1,698.09 43640 1,020.98 969.93 1,115.42 44143 1,449.05 1,376.60 1,583.09 43641 1,029.83 978.34 1,125.09 44144 1,523.10 1,446.95 1,663.99 43644 1,511.58 1,436.00 1,651.40 44145 1,462.39 1,389.27 1,597.66 43645 1,615.72 1,534.93 1,765.17 44146 1,835.71 1,743.92 2,005.51 43651 568.14 539.73 620.69 44147 1,654.39 1,571.67 1,807.42 43652 664.55 631.32 726.02 44150 1,611.20 1,530.64 1,760.24 43653 486.57 462.24 531.58 44151 1,840.99 1,748.94 2,011.28 43752 40.04 38.04 43.75 44155 1,804.47 1,714.25 1,971.39 43760 321.38 305.31 351.11 44156 1,981.17 1,882.11 2,164.43 # 43760 47.82 45.43 52.24 44157 1,879.86 1,785.87 2,053.75 43761 117.00 111.15 127.82 44158 1,926.33 1,830.01 2,104.51 # 43761 102.76 97.62 112.26 44160 1,082.37 1,028.25 1,182.49 43770 969.57 921.09 1,059.25 44180 807.06 766.71 881.72 43771 1,104.68 1,049.45 1,206.87 44186 570.65 542.12 623.44 43772 835.35 793.58 912.62 44187 963.56 915.38 1,052.69 43773 1,105.59 1,050.31 1,207.86 44188 1,065.19 1,011.93 1,163.72 43774 836.96 795.11 914.38 44202 1,214.29 1,153.58 1,326.62 43800 810.29 769.78 885.25 44203 216.85 206.01 236.91 43810 878.07 834.17 959.30 44204 1,355.63 1,287.85 1,481.03 43820 1,139.80 1,082.81 1,245.23 44205 1,183.58 1,124.40 1,293.06 43825 1,129.35 1,072.88 1,233.81 44206 1,539.26 1,462.30 1,681.65 43830 603.78 573.59 659.63 44207 1,615.04 1,534.29 1,764.43 43831 506.39 481.07 553.23 44208 1,758.78 1,670.84 1,921.47 43832 927.18 880.82 1,012.94 44210 1,573.47 1,494.80 1,719.02 43840 1,156.20 1,098.39 1,263.15 44211 1,931.38 1,834.81 2,110.03 43843 1,101.06 1,046.01 1,202.91 44212 1,813.35 1,722.68 1,981.08 43845 1,701.36 1,616.29 1,858.73 44213 171.04 162.49 186.86 43846 1,419.72 1,348.73 1,551.04 44227 1,467.58 1,394.20 1,603.33 43847 1,549.63 1,472.15 1,692.97 44300 732.57 695.94 800.33 43848 1,681.90 1,597.81 1,837.48 44310 915.03 869.28 999.67 43850 1,407.80 1,337.41 1,538.02 44312 523.83 497.64 572.29 43855 1,471.23 1,397.67 1,607.32 44314 888.29 843.88 970.46 43860 1,429.97 1,358.47 1,562.24 44316 1,214.42 1,153.70 1,326.76 43865 1,486.76 1,412.42 1,624.28 44320 1,044.14 991.93 1,140.72 43870 615.25 584.49 672.16 44322 838.32 796.40 915.86 43880 1,396.95 1,327.10 1,526.17 44340 527.17 500.81 575.93 43886 295.32 280.55 322.63 44345 914.56 868.83 999.15 43887 274.96 261.21 300.39 44346 1,026.63 975.30 1,121.60 43888 387.60 368.22 423.45 44360 150.54 143.01 164.46 44005 955.42 907.65 1,043.80 44361 165.84 157.55 181.18 44010 752.35 714.73 821.94 44363 195.95 186.15 214.07 44015 129.56 123.08 141.54 44364 211.35 200.78 230.90 44020 845.07 802.82 923.24 44365 188.21 178.80 205.62 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 38 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 44366 249.09 236.64 272.14 45005 223.94 212.74 244.65 44369 254.35 241.63 277.87 # 45005 135.51 128.73 148.04 44370 274.11 260.40 299.46 45020 475.09 451.34 519.04 44372 241.72 229.63 264.07 45100 252.83 240.19 276.22 44373 195.95 186.15 214.07 45108 306.65 291.32 335.02 44376 289.28 274.82 316.04 45110 1,620.96 1,539.91 1,770.90 44377 307.31 291.94 335.73 45111 951.40 903.83 1,039.40 44378 393.99 374.29 430.43 45112 1,667.73 1,584.34 1,821.99 44379 417.29 396.43 455.89 45113 1,712.14 1,626.53 1,870.51 44380 65.81 62.52 71.90 45114 1,561.30 1,483.24 1,705.73 44382 78.91 74.96 86.20 45116 1,403.98 1,333.78 1,533.85 44383 169.12 160.66 184.76 45119 1,715.23 1,629.47 1,873.89 44385 233.02 221.37 254.58 45120 1,369.80 1,301.31 1,496.51 # 44385 100.37 95.35 109.65 45121 1,497.77 1,422.88 1,636.31 44386 324.87 308.63 354.92 45123 973.00 924.35 1,063.00 # 44386 117.64 111.76 128.52 45126 2,541.07 2,414.02 2,776.12 44388 321.89 305.80 351.67 45130 951.48 903.91 1,039.50 # 44388 156.25 148.44 170.71 45135 1,164.59 1,106.36 1,272.31 44389 374.45 355.73 409.09 45136 1,616.38 1,535.56 1,765.89 # 44389 174.72 165.98 190.88 45150 349.42 331.95 381.74 44390 432.02 410.42 471.98 45160 866.76 823.42 946.93 # 44390 209.43 198.96 228.80 45170 677.58 643.70 740.26 44391 484.13 459.92 528.91 45190 591.19 561.63 645.87 # 44391 239.06 227.11 261.18 45300 98.47 93.55 107.58 44392 404.64 384.41 442.07 # 45300 45.26 43.00 49.45 # 44392 205.66 195.38 224.69 45303 775.17 736.41 846.87 44393 469.37 445.90 512.79 # 45303 77.04 73.19 84.17 # 44393 262.14 249.03 286.38 45305 160.09 152.09 174.90 44394 473.78 450.09 517.60 # 45305 69.03 65.58 75.42 # 44394 242.94 230.79 265.41 45307 177.81 168.92 194.26 44397 262.57 249.44 286.86 # 45307 87.13 82.77 95.19 44500 24.92 23.67 27.22 45308 163.29 155.13 178.40 44602 1,207.30 1,146.94 1,318.98 # 45308 74.10 70.40 80.96 44603 1,384.41 1,315.19 1,512.47 45309 182.93 173.78 199.85 44604 926.14 879.83 1,011.80 # 45309 85.50 81.23 93.41 44605 1,143.49 1,086.32 1,249.27 45315 197.45 187.58 215.72 44615 942.14 895.03 1,029.28 # 45315 97.77 92.88 106.81 44620 753.69 716.01 823.41 45317 190.42 180.90 208.04 44625 891.54 846.96 974.00 # 45317 102.74 97.60 112.24 44626 1,413.86 1,343.17 1,544.65 45320 192.03 182.43 209.79 44640 1,234.40 1,172.68 1,348.58 # 45320 97.97 93.07 107.03 44650 1,283.57 1,219.39 1,402.30 45321 94.89 90.15 103.67 44660 1,251.87 1,189.28 1,367.67 45327 110.77 105.23 121.01 44661 1,398.35 1,328.43 1,527.69 45330 127.02 120.67 138.77 44680 930.77 884.23 1,016.86 # 45330 58.44 55.52 63.85 44700 901.79 856.70 985.21 45331 161.77 153.68 176.73 44701 150.95 143.40 164.91 # 45331 71.08 67.53 77.66 44715 355.62 337.84 388.52 45332 265.83 252.54 290.42 44720 249.83 237.34 272.94 # 45332 103.57 98.39 113.15 44721 346.57 329.24 378.63 45333 267.54 254.16 292.28 44800 664.23 631.02 725.67 # 45333 103.03 97.88 112.56 44820 732.80 696.16 800.58 45334 156.51 148.68 170.98 44850 646.66 614.33 706.48 45335 229.12 217.66 250.31 44900 663.07 629.92 724.41 # 45335 86.34 82.02 94.32 44901 944.00 896.80 1,031.32 45337 133.58 126.90 145.94 # 44901 171.68 163.10 187.57 45338 297.79 282.90 325.34 44950 560.14 532.13 611.95 # 45338 134.03 127.33 146.43 44955 75.75 71.96 82.75 45339 307.20 291.84 335.62 44960 754.88 717.14 824.71 # 45339 177.16 168.30 193.55 44970 516.23 490.42 563.98 45340 410.17 389.66 448.11 45000 363.81 345.62 397.46 # 45340 108.51 103.08 118.54 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 39 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 45341 149.40 141.93 163.22 46070 201.13 191.07 219.73 45342 228.26 216.85 249.38 46080 203.09 192.94 221.88 45345 165.73 157.44 181.06 # 46080 138.26 131.35 151.05 45355 189.55 180.07 207.08 46083 155.27 147.51 169.64 45378 371.92 353.32 406.32 # 46083 93.81 89.12 102.49 # 45378 204.79 194.55 223.73 46200 342.98 325.83 374.70 45378 53 127.02 120.67 138.77 # 46200 263.54 250.36 287.91 # 45378 53 58.44 55.52 63.85 46210 316.10 300.30 345.35 45379 472.08 448.48 515.75 # 46210 222.42 211.30 243.00 # 45379 256.23 243.42 279.93 46211 426.13 404.82 465.54 45380 446.66 424.33 487.98 # 46211 323.08 306.93 352.97 # 45380 246.92 234.57 269.76 46220 165.49 157.22 180.80 45381 435.29 413.53 475.56 # 46220 100.29 95.28 109.57 # 45381 234.06 222.36 255.71 46221 216.05 205.25 236.04 45382 589.42 559.95 643.94 # 46221 159.84 151.85 174.63 # 45382 315.87 300.08 345.09 46230 225.45 214.18 246.31 45383 530.00 503.50 579.03 # 46230 149.00 141.55 162.78 # 45383 316.78 300.94 346.08 46250 375.74 356.95 410.49 45384 437.80 415.91 478.30 # 46250 264.07 250.87 288.50 # 45384 256.05 243.25 279.74 46255 418.38 397.46 457.08 45385 502.81 477.67 549.32 # 46255 299.96 284.96 327.70 # 45385 292.96 278.31 320.06 46257 351.18 333.62 383.66 45386 625.12 593.86 682.94 46258 383.97 364.77 419.49 # 45386 251.52 238.94 274.78 46260 398.28 378.37 435.13 45387 328.34 311.92 358.71 46261 445.36 423.09 486.55 45391 283.51 269.33 309.73 46262 465.28 442.02 508.32 45392 359.42 341.45 392.67 46270 405.98 385.68 443.53 45395 1,752.75 1,665.11 1,914.88 # 46270 318.30 302.39 347.75 45397 1,899.13 1,804.17 2,074.80 46275 429.14 407.68 468.83 45400 1,011.32 960.75 1,104.86 # 46275 340.70 323.67 372.22 45402 1,350.67 1,283.14 1,475.61 46280 389.26 369.80 425.27 45500 448.06 425.66 489.51 46285 417.31 396.44 455.91 45505 491.45 466.88 536.91 # 46285 336.75 319.91 367.90 45520 115.10 109.35 125.75 46288 459.53 436.55 502.03 # 45520 34.91 33.16 38.13 46320 148.74 141.30 162.50 45540 932.94 886.29 1,019.23 # 46320 94.78 90.04 103.55 45541 803.68 763.50 878.03 46500 182.10 173.00 198.95 45550 1,282.67 1,218.54 1,401.32 # 46500 108.28 102.87 118.30 45560 637.56 605.68 696.53 46505 236.26 224.45 258.12 45562 975.78 926.99 1,066.04 # 46505 198.79 188.85 217.18 45563 1,408.57 1,338.14 1,538.86 46600 73.51 69.83 80.30 45800 1,097.20 1,042.34 1,198.69 # 46600 34.53 32.80 37.72 45805 1,239.32 1,177.35 1,353.95 46604 463.72 440.53 506.61 45820 1,091.33 1,036.76 1,192.27 # 46604 59.38 56.41 64.87 45825 1,310.83 1,245.29 1,432.08 46606 188.68 179.25 206.14 45900 173.21 164.55 189.23 # 46606 65.76 62.47 71.84 45905 147.38 140.01 161.01 46608 194.20 184.49 212.16 45910 174.53 165.80 190.67 # 46608 72.04 68.44 78.71 45915 276.36 262.54 301.92 46610 192.19 182.58 209.97 # 45915 195.79 186.00 213.90 # 46610 71.52 67.94 78.13 45990 96.61 91.78 105.55 46611 150.48 142.96 164.40 46020 222.12 211.01 242.66 # 46611 73.66 69.98 80.48 # 46020 193.64 183.96 211.55 46612 229.64 218.16 250.88 46030 112.26 106.65 122.65 # 46612 86.87 82.53 94.91 # 46030 76.66 72.83 83.75 46614 115.10 109.35 125.75 46040 434.25 412.54 474.42 # 46614 62.26 59.15 68.02 # 46040 346.56 329.23 378.61 46615 131.17 124.61 143.30 46045 356.85 339.01 389.86 # 46615 88.08 83.68 96.23 46050 157.64 149.76 172.22 46700 552.53 524.90 603.64 # 46050 81.20 77.14 88.71 46705 456.04 433.24 498.23 46060 392.48 372.86 428.79 46706 146.30 138.99 159.84 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 40 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 46710 941.52 894.44 1,028.61 47142 4,026.29 3,824.98 4,398.73 46712 1,910.71 1,815.17 2,087.45 47143 301.07 286.02 328.92 46715 449.91 427.41 491.52 47144 451.59 429.01 493.36 46716 1,109.18 1,053.72 1,211.78 47145 451.59 429.01 493.36 46730 1,669.65 1,586.17 1,824.10 47146 295.43 280.66 322.76 46735 1,946.31 1,848.99 2,126.34 47147 344.70 327.47 376.59 46740 1,791.28 1,701.72 1,956.98 47300 973.14 924.48 1,063.15 46742 2,114.02 2,008.32 2,309.57 47350 1,192.49 1,132.87 1,302.80 46744 2,996.41 2,846.59 3,273.58 47360 1,622.31 1,541.19 1,772.37 46746 3,465.02 3,291.77 3,785.54 47361 2,661.74 2,528.65 2,907.95 46748 3,650.89 3,468.35 3,988.60 47362 1,238.39 1,176.47 1,352.94 46750 667.70 634.32 729.47 47370 1,088.31 1,033.89 1,188.97 46751 556.22 528.41 607.67 47371 1,109.38 1,053.91 1,212.00 46753 503.91 478.71 550.52 47380 1,272.93 1,209.28 1,390.67 46754 245.31 233.04 268.00 47381 1,298.80 1,233.86 1,418.94 # 46754 187.23 177.87 204.55 47382 812.67 772.04 887.85 46760 943.99 896.79 1,031.31 47400 1,856.03 1,763.23 2,027.71 46761 815.30 774.54 890.72 47420 1,166.79 1,108.45 1,274.72 46762 805.71 765.42 880.23 47425 1,178.60 1,119.67 1,287.62 46900 199.13 189.17 217.55 47460 1,116.20 1,060.39 1,219.45 # 46900 121.56 115.48 132.80 47480 744.55 707.32 813.42 46910 207.75 197.36 226.96 47490 506.98 481.63 553.87 # 46910 115.94 110.14 126.66 47500 100.79 95.75 110.11 46916 206.42 196.10 225.52 47505 38.94 36.99 42.54 # 46916 128.85 122.41 140.77 47510 479.15 455.19 523.47 46917 400.69 380.66 437.76 47511 600.04 570.04 655.55 # 46917 116.65 110.82 127.44 47525 579.67 550.69 633.29 46922 216.49 205.67 236.52 # 47525 123.62 117.44 135.06 # 46922 115.69 109.91 126.40 47530 1,399.65 1,329.67 1,529.12 46924 452.72 430.08 494.59 # 47530 359.77 341.78 393.05 # 46924 161.56 153.48 176.50 47550 149.31 141.84 163.12 46930 191.59 182.01 209.31 47552 324.53 308.30 354.55 # 46930 137.25 130.39 149.95 47553 324.39 308.17 354.40 46937 222.25 211.14 242.81 47554 472.06 448.46 515.73 # 46937 155.17 147.41 169.52 47555 389.22 369.76 425.22 46938 385.28 366.02 420.92 47556 440.36 418.34 481.09 # 46938 315.95 300.15 345.17 47560 241.17 229.11 263.48 46940 186.05 176.75 203.26 47561 262.29 249.18 286.56 # 46940 128.34 121.92 140.21 47562 643.14 610.98 702.63 46942 172.66 164.03 188.63 47563 657.32 624.45 718.12 # 46942 114.20 108.49 124.76 47564 758.35 720.43 828.49 46945 242.62 230.49 265.06 47570 677.60 643.72 740.28 # 46945 185.66 176.38 202.84 47600 923.31 877.14 1,008.71 46946 261.66 248.58 285.87 47605 852.52 809.89 931.37 # 46946 194.95 185.20 212.98 47610 1,092.15 1,037.54 1,193.17 46947 325.17 308.91 355.25 47612 1,103.57 1,048.39 1,205.65 47000 313.35 297.68 342.33 47620 1,197.47 1,137.60 1,308.24 # 47000 97.88 92.99 106.94 47630 544.10 516.90 594.44 47001 93.30 88.64 101.94 47700 911.17 865.61 995.45 47010 1,045.18 992.92 1,141.86 47701 1,565.71 1,487.42 1,710.53 47011 189.59 180.11 207.13 47711 1,356.49 1,288.67 1,481.97 47015 990.37 940.85 1,081.98 47712 1,735.63 1,648.85 1,896.18 47100 725.50 689.23 792.61 47715 1,141.18 1,084.12 1,246.74 47120 2,033.11 1,931.45 2,221.17 47720 986.85 937.51 1,078.14 47122 3,019.90 2,868.91 3,299.25 47721 1,163.33 1,105.16 1,270.93 47125 2,705.22 2,569.96 2,955.45 47740 1,124.35 1,068.13 1,228.35 47130 2,908.41 2,762.99 3,177.44 47741 1,272.76 1,209.12 1,390.49 47135 4,284.40 4,070.18 4,680.71 47760 1,919.34 1,823.37 2,096.88 47136 3,655.91 3,473.11 3,994.08 47765 2,539.75 2,412.76 2,774.67 47140 3,065.87 2,912.58 3,349.47 47780 2,099.79 1,994.80 2,294.02 47141 3,654.86 3,472.12 3,992.94 47785 2,738.94 2,601.99 2,992.29 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 41 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 47800 1,369.72 1,301.23 1,496.41 49320 289.97 275.47 316.79 47801 979.18 930.22 1,069.75 49321 304.99 289.74 333.20 47802 1,316.09 1,250.29 1,437.83 49322 331.71 315.12 362.39 47900 1,185.69 1,126.41 1,295.37 49323 563.35 535.18 615.46 48000 1,643.31 1,561.14 1,795.31 49324 345.10 327.85 377.03 48001 2,015.70 1,914.92 2,202.16 49325 369.80 351.31 404.01 48020 1,014.98 964.23 1,108.86 49326 169.16 160.70 184.81 48100 770.47 731.95 841.74 49400 170.36 161.84 186.12 48102 521.21 495.15 569.42 # 49400 95.79 91.00 104.65 # 48102 250.65 238.12 273.84 49402 746.63 709.30 815.70 48105 2,485.64 2,361.36 2,715.56 49419 401.20 381.14 438.31 48120 961.03 912.98 1,049.93 49420 127.79 121.40 139.61 48140 1,359.69 1,291.71 1,485.47 49421 343.96 326.76 375.77 48145 1,411.64 1,341.06 1,542.22 49422 343.41 326.24 375.18 48146 1,613.39 1,532.72 1,762.63 49423 554.42 526.70 605.71 48148 1,071.44 1,017.87 1,170.55 # 49423 76.64 72.81 83.73 48150 2,717.73 2,581.84 2,969.12 49424 149.87 142.38 163.74 48152 2,513.69 2,388.01 2,746.21 # 49424 40.07 38.07 43.78 48153 2,713.85 2,578.16 2,964.88 49425 671.50 637.93 733.62 48154 2,519.65 2,393.67 2,752.72 49426 572.27 543.66 625.21 48155 1,566.58 1,488.25 1,711.49 49427 46.01 43.71 50.27 48400 99.44 94.47 108.64 49428 386.01 366.71 421.72 48500 982.39 933.27 1,073.26 49429 405.66 385.38 443.19 48510 933.96 887.26 1,020.35 49435 108.30 102.89 118.32 48511 913.48 867.81 997.98 49436 162.02 153.92 177.01 # 48511 205.24 194.98 224.23 49440 1,074.02 1,020.32 1,173.37 48520 950.23 902.72 1,038.13 # 49440 230.50 218.98 251.83 48540 1,133.94 1,077.24 1,238.83 49441 1,167.66 1,109.28 1,275.67 48545 1,150.38 1,092.86 1,256.79 # 49441 256.31 243.49 280.01 48547 1,548.96 1,471.51 1,692.24 49442 1,047.25 994.89 1,144.12 48548 1,450.92 1,378.37 1,585.13 # 49442 211.60 201.02 231.17 48551 204.63 194.40 223.56 49446 979.39 930.42 1,069.98 48552 208.59 198.16 227.88 # 49446 170.35 161.83 186.10 48554 2,169.44 2,060.97 2,370.12 49450 735.02 698.27 803.01 48556 1,079.70 1,025.72 1,179.58 # 49450 68.00 64.60 74.29 49000 676.73 642.89 739.32 49451 698.49 663.57 763.11 49002 890.38 845.86 972.74 # 49451 94.80 90.06 103.57 49010 840.58 798.55 918.33 49452 878.47 834.55 959.73 49020 1,387.79 1,318.40 1,516.16 # 49452 147.75 140.36 161.41 49021 873.97 830.27 954.81 49460 807.03 766.68 881.68 # 49021 173.22 164.56 189.24 # 49460 48.57 46.14 53.06 49040 870.88 827.34 951.44 49465 167.88 159.49 183.41 49041 891.00 846.45 973.42 # 49465 31.85 30.26 34.80 # 49041 204.86 194.62 223.81 49491 675.88 642.09 738.40 49060 976.05 927.25 1,066.34 49492 824.40 783.18 900.66 49061 876.10 832.30 957.15 49495 343.94 326.74 375.75 # 49061 189.59 180.11 207.13 49496 522.22 496.11 570.53 49062 662.64 629.51 723.94 49500 343.24 326.08 374.99 49080 164.32 156.10 179.52 49501 517.87 491.98 565.78 # 49080 69.13 65.67 75.52 49505 448.64 426.21 490.14 49081 153.37 145.70 167.56 49507 551.62 524.04 602.65 # 49081 64.93 61.68 70.93 49520 547.38 520.01 598.01 49180 164.11 155.90 179.29 49521 666.76 633.42 728.43 # 49180 88.79 84.35 97.00 49525 495.41 470.64 541.24 49203 1,060.07 1,007.07 1,158.13 49540 585.30 556.04 639.45 49204 1,352.46 1,284.84 1,477.57 49550 497.74 472.85 543.78 49205 1,547.86 1,470.47 1,691.04 49553 544.56 517.33 594.93 49215 1,939.76 1,842.77 2,119.19 49555 518.03 492.13 565.95 49220 845.44 803.17 923.65 49557 628.44 597.02 686.57 49250 506.45 481.13 553.30 49560 642.35 610.23 701.76 49255 687.26 652.90 750.84 49561 809.65 769.17 884.55 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 42 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 49565 666.44 633.12 728.09 50360 2,209.80 2,099.31 2,414.21 49566 818.02 777.12 893.69 50365 2,488.04 2,363.64 2,718.19 49568 239.88 227.89 262.07 50370 1,034.48 982.76 1,130.17 49570 354.10 336.40 386.86 50380 1,756.85 1,669.01 1,919.36 49572 438.39 416.47 478.94 50382 1,293.38 1,228.71 1,413.02 49580 276.75 262.91 302.35 # 50382 286.10 271.80 312.57 49582 409.08 388.63 446.92 50384 1,111.84 1,056.25 1,214.69 49585 380.36 361.34 415.54 # 50384 260.44 247.42 284.53 49587 450.11 427.60 491.74 50385 1,267.85 1,204.46 1,385.13 49590 493.57 468.89 539.22 # 50385 245.20 232.94 267.88 49600 638.03 606.13 697.05 50386 820.85 779.81 896.78 49605 4,387.94 4,168.54 4,793.82 # 50386 185.31 176.04 202.45 49606 992.43 942.81 1,084.23 50387 599.88 569.89 655.37 49610 594.30 564.59 649.28 # 50387 103.74 98.55 113.33 49611 538.09 511.19 587.87 50389 348.12 330.71 380.32 49650 369.00 350.55 403.13 # 50389 56.95 54.10 62.22 49651 477.25 453.39 521.40 50390 100.79 95.75 110.11 49652 692.46 657.84 756.52 50391 130.73 124.19 142.82 49653 865.28 822.02 945.32 # 50391 102.63 97.50 112.13 49654 795.28 755.52 868.85 50392 185.58 176.30 202.75 49655 957.12 909.26 1,045.65 50393 226.17 214.86 247.09 49656 797.96 758.06 871.77 50394 106.56 101.23 116.41 49657 1,150.73 1,093.19 1,257.17 # 50394 51.48 48.91 56.25 49900 709.37 673.90 774.99 50395 186.87 177.53 204.16 49904 1,326.51 1,260.18 1,449.21 50396 121.01 114.96 132.20 49905 321.07 305.02 350.77 50398 539.06 512.11 588.93 50010 699.93 664.93 764.67 # 50398 76.64 72.81 83.73 50020 996.96 947.11 1,089.18 50400 1,181.56 1,122.48 1,290.85 50021 920.06 874.06 1,005.17 50405 1,432.30 1,360.69 1,564.79 # 50021 172.84 164.20 188.83 50500 1,136.84 1,080.00 1,242.00 50040 942.43 895.31 1,029.61 50520 1,057.85 1,004.96 1,155.70 50045 949.78 902.29 1,037.63 50525 1,320.53 1,254.50 1,442.68 50060 1,170.44 1,111.92 1,278.71 50526 1,380.33 1,311.31 1,508.01 50065 1,228.18 1,166.77 1,341.79 50540 1,156.74 1,098.90 1,263.74 50070 1,222.97 1,161.82 1,336.09 50541 943.33 896.16 1,030.58 50075 1,502.48 1,427.36 1,641.46 50542 1,197.38 1,137.51 1,308.14 50080 894.73 849.99 977.49 50543 1,527.21 1,450.85 1,668.48 50081 1,313.04 1,247.39 1,434.50 50544 1,286.05 1,221.75 1,405.01 50100 947.74 900.35 1,035.40 50545 1,380.31 1,311.29 1,507.98 50120 968.59 920.16 1,058.18 50546 1,224.40 1,163.18 1,337.66 50125 999.88 949.89 1,092.37 50547 1,462.08 1,388.98 1,597.33 50130 1,060.93 1,007.88 1,159.06 50548 1,391.42 1,321.85 1,520.13 50135 1,148.33 1,090.91 1,254.55 50551 380.28 361.27 415.46 50200 145.11 137.85 158.53 # 50551 306.46 291.14 334.81 50205 668.91 635.46 730.78 50553 396.80 376.96 433.50 50220 1,042.68 990.55 1,139.13 # 50553 323.73 307.54 353.67 50225 1,207.81 1,147.42 1,319.53 50555 432.64 411.01 472.66 50230 1,310.08 1,244.58 1,431.27 # 50555 354.32 336.60 387.09 50234 1,330.29 1,263.78 1,453.35 50557 441.47 419.40 482.31 50236 1,506.55 1,431.22 1,645.90 # 50557 359.78 341.79 393.06 50240 1,353.46 1,285.79 1,478.66 50561 500.48 475.46 546.78 50250 1,256.85 1,194.01 1,373.11 # 50561 410.92 390.37 448.93 50280 964.68 916.45 1,053.92 50562 606.15 575.84 662.22 50290 886.48 842.16 968.48 50570 512.81 487.17 560.25 50320 1,309.43 1,243.96 1,430.55 50572 557.23 529.37 608.78 50323 183.98 174.78 201.00 50574 589.43 559.96 643.95 50325 183.98 174.78 201.00 50575 745.20 707.94 814.13 50327 195.19 185.43 213.24 50576 588.52 559.09 642.95 50328 171.41 162.84 187.27 50580 630.10 598.60 688.39 50329 169.60 161.12 185.29 50590 957.33 909.46 1,045.88 50340 805.43 765.16 879.93 # 50590 577.73 548.84 631.17 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 43 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 50592 3,692.12 3,507.51 4,033.64 50980 371.61 353.03 405.98 # 50592 372.75 354.11 407.23 51020 476.11 452.30 520.15 50593 4,764.61 4,526.38 5,205.34 51030 470.27 446.76 513.77 # 50593 471.68 448.10 515.32 51040 297.97 283.07 325.53 50600 957.55 909.67 1,046.12 51045 473.77 450.08 517.59 50605 918.82 872.88 1,003.81 51050 482.75 458.61 527.40 50610 975.55 926.77 1,065.79 51060 594.22 564.51 649.19 50620 927.61 881.23 1,013.41 51065 589.89 560.40 644.46 50630 903.52 858.34 987.09 51080 413.82 393.13 452.10 50650 1,057.35 1,004.48 1,155.15 51100 62.32 59.20 68.08 50660 1,168.42 1,110.00 1,276.50 # 51100 39.46 37.49 43.11 50684 185.26 176.00 202.40 51101 128.76 122.32 140.67 # 50684 51.10 48.55 55.83 # 51101 52.69 50.06 57.57 50686 93.02 88.37 101.63 51102 241.45 229.38 263.79 50688 81.57 77.49 89.11 # 51102 153.76 146.07 167.98 50690 102.21 97.10 111.67 51500 631.35 599.78 689.75 # 50690 71.86 68.27 78.51 51520 597.64 567.76 652.92 50700 945.97 898.67 1,033.47 51525 878.23 834.32 959.47 50715 1,109.67 1,054.19 1,212.32 51530 781.21 742.15 853.47 50722 964.98 916.73 1,054.24 51535 792.19 752.58 865.47 50725 1,110.45 1,054.93 1,213.17 51550 963.08 914.93 1,052.17 50727 512.80 487.16 560.23 51555 1,280.51 1,216.48 1,398.95 50728 703.16 668.00 768.20 51565 1,310.16 1,244.65 1,431.35 50740 1,088.16 1,033.75 1,188.81 51570 1,496.29 1,421.48 1,634.70 50750 1,189.50 1,130.03 1,299.53 51575 1,870.99 1,777.44 2,044.06 50760 1,106.64 1,051.31 1,209.01 51580 1,950.53 1,853.00 2,130.95 50770 1,149.07 1,091.62 1,255.36 51585 2,172.24 2,063.63 2,373.17 50780 1,110.64 1,055.11 1,213.38 51590 1,978.09 1,879.19 2,161.07 50782 1,089.10 1,034.65 1,189.85 51595 2,248.12 2,135.71 2,456.07 50783 1,126.24 1,069.93 1,230.42 51596 2,417.18 2,296.32 2,640.77 50785 1,234.22 1,172.51 1,348.39 51597 2,329.50 2,213.03 2,544.98 50800 937.95 891.05 1,024.71 51600 199.12 189.16 217.53 50810 1,224.68 1,163.45 1,337.97 # 51600 45.48 43.21 49.69 50815 1,250.36 1,187.84 1,366.02 51605 39.49 37.52 43.15 50820 1,328.35 1,261.93 1,451.22 51610 114.36 108.64 124.94 50825 1,688.20 1,603.79 1,844.36 # 51610 65.27 62.01 71.31 50830 1,830.50 1,738.98 1,999.83 51700 89.70 85.22 98.00 50840 1,259.13 1,196.17 1,375.60 # 51700 45.48 43.21 49.69 50845 1,277.25 1,213.39 1,395.40 51701 62.54 59.41 68.32 50860 966.36 918.04 1,055.75 # 51701 27.69 26.31 30.26 50900 850.19 807.68 928.83 51702 80.91 76.86 88.39 50920 900.90 855.86 984.24 # 51702 30.69 29.16 33.53 50930 1,087.36 1,032.99 1,187.94 51703 144.62 137.39 158.00 50940 904.15 858.94 987.78 # 51703 83.91 79.71 91.67 50945 1,002.93 952.78 1,095.70 51705 116.63 110.80 127.42 50947 1,419.22 1,348.26 1,550.50 # 51705 68.67 65.24 75.03 50948 1,320.22 1,254.21 1,442.34 51710 164.23 156.02 179.42 50951 397.35 377.48 434.10 # 51710 97.53 92.65 106.55 # 50951 319.78 303.79 349.36 51715 301.62 286.54 329.52 50953 419.23 398.27 458.01 # 51715 203.81 193.62 222.66 # 50953 352.52 334.89 385.12 51720 119.39 113.42 130.43 50955 463.93 440.73 506.84 # 51720 85.29 81.03 93.18 # 50955 380.74 361.70 415.96 51725 227.25 215.89 248.27 50957 450.76 428.22 492.45 51725 TC 149.44 141.97 163.27 # 50957 368.70 350.27 402.81 51725 26 77.82 73.93 85.02 50961 407.17 386.81 444.83 51726 331.86 315.27 362.56 # 50961 330.35 313.83 360.90 51726 TC 243.28 231.12 265.79 50970 386.86 367.52 422.65 51726 26 88.57 84.14 96.76 50972 372.47 353.85 406.93 51736 54.85 52.11 59.93 50974 493.18 468.52 538.80 51736 TC 23.03 21.88 25.16 50976 485.45 461.18 530.36 51736 26 31.83 30.24 34.78 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 44 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 51741 86.42 82.10 94.42 52270 426.09 404.79 465.51 51741 TC 26.94 25.59 29.43 # 52270 188.89 179.45 206.37 51741 26 59.48 56.51 64.99 52275 582.73 553.59 636.63 51772 254.39 241.67 277.92 # 52275 258.59 245.66 282.51 51772 TC 172.09 163.49 188.01 52276 276.11 262.30 301.65 51772 26 82.30 78.19 89.92 52277 337.05 320.20 368.23 51784 208.12 197.71 227.37 52281 319.79 303.80 349.37 51784 TC 129.57 123.09 141.55 # 52281 160.15 152.14 174.96 51784 26 78.54 74.61 85.80 52282 347.76 330.37 379.93 51785 226.31 214.99 247.24 52283 292.50 277.88 319.56 51785 TC 147.56 140.18 161.21 # 52283 207.81 197.42 227.03 51785 26 78.75 74.81 86.03 52285 294.93 280.18 322.21 51792 237.87 225.98 259.88 # 52285 201.25 191.19 219.87 51792 TC 181.29 172.23 198.06 52290 254.08 241.38 277.59 51792 26 56.58 53.75 61.81 52300 291.54 276.96 318.50 51795 312.54 296.91 341.45 52301 306.08 290.78 334.40 51795 TC 233.63 221.95 255.24 52305 289.67 275.19 316.47 51795 26 78.92 74.97 86.22 52310 262.44 249.32 286.72 51797 153.85 146.16 168.08 # 52310 157.14 149.28 171.67 51797 TC 109.13 103.67 119.22 52315 463.89 440.70 506.81 51797 26 44.72 42.48 48.85 # 52315 285.52 271.24 311.93 51798 20.82 19.78 22.75 52317 1,000.22 950.21 1,092.74 51800 1,065.87 1,012.58 1,164.47 # 52317 362.05 343.95 395.54 51820 1,081.84 1,027.75 1,181.91 52318 493.31 468.64 538.94 51840 646.71 614.37 706.53 52320 256.34 243.52 280.05 51841 767.11 728.75 838.06 52325 333.32 316.65 364.15 51845 591.45 561.88 646.16 52327 554.23 526.52 605.50 51860 720.87 684.83 787.55 # 52327 272.43 258.81 297.63 51865 894.41 849.69 977.14 52330 814.71 773.97 890.07 51880 468.68 445.25 512.04 # 52330 274.35 260.63 299.72 51900 829.08 787.63 905.77 52332 504.66 479.43 551.34 51920 766.21 727.90 837.09 # 52332 161.78 153.69 176.74 51925 994.38 944.66 1,086.36 52334 266.61 253.28 291.27 51940 1,636.15 1,554.34 1,787.49 52341 303.17 288.01 331.21 51960 1,417.19 1,346.33 1,548.28 52342 329.58 313.10 360.07 51980 726.81 690.47 794.04 52343 366.52 348.19 400.42 51990 741.61 704.53 810.21 52344 397.59 377.71 434.37 51992 809.14 768.68 883.98 52345 423.99 402.79 463.21 52000 217.29 206.43 237.39 52346 478.42 454.50 522.68 # 52000 128.85 122.41 140.77 52351 326.49 310.17 356.70 52001 396.44 376.62 433.11 52352 383.35 364.18 418.81 # 52001 297.88 282.99 325.44 52353 440.86 418.82 481.64 52005 301.16 286.10 329.02 52354 407.56 387.18 445.26 # 52005 137.40 130.53 150.11 52355 485.63 461.35 530.55 52007 566.76 538.42 619.18 52400 499.42 474.45 545.62 # 52007 171.79 163.20 187.68 52402 278.80 264.86 304.59 52010 420.45 399.43 459.34 52450 478.67 454.74 522.95 # 52010 166.38 158.06 181.77 52500 499.78 474.79 546.01 52204 464.23 441.02 507.17 52601 846.10 803.80 924.37 # 52204 145.71 138.42 159.18 52630 453.79 431.10 495.77 52214 609.19 578.73 665.54 52640 309.96 294.46 338.63 # 52214 226.22 214.91 247.15 52647 2,277.47 2,163.60 2,488.14 52224 874.62 830.89 955.52 # 52647 660.51 627.48 721.60 # 52224 175.75 166.96 192.00 52648 2,324.49 2,208.27 2,539.51 52234 256.07 243.27 279.76 # 52648 704.53 669.30 769.70 52235 300.13 285.12 327.89 52649 1,007.26 956.90 1,100.44 52240 524.34 498.12 572.84 52700 443.53 421.35 484.55 52250 251.59 239.01 274.86 53000 152.32 144.70 166.41 52260 216.89 206.05 236.96 53010 299.54 284.56 327.24 52265 442.84 420.70 483.81 53020 100.48 95.46 109.78 # 52265 163.29 155.13 178.40 53025 66.07 62.77 72.19 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 45 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 53040 401.21 381.15 438.32 53852 2,520.84 2,394.80 2,754.02 53060 176.31 167.49 192.61 # 53852 634.44 602.72 693.13 # 53060 155.33 147.56 169.69 54000 162.27 154.16 177.28 53080 445.38 423.11 486.58 # 54000 109.81 104.32 119.97 53085 626.34 595.02 684.27 54001 198.75 188.81 217.13 53200 158.95 151.00 173.65 # 54001 141.04 133.99 154.09 # 53200 144.34 137.12 157.69 54015 317.36 301.49 346.71 53210 787.15 747.79 859.96 54050 122.10 116.00 133.40 53215 955.62 907.84 1,044.02 # 54050 96.62 91.79 105.56 53220 460.74 437.70 503.36 54055 116.52 110.69 127.29 53230 612.97 582.32 669.67 # 54055 88.79 84.35 97.00 53235 652.88 620.24 713.28 54056 127.76 121.37 139.58 53240 438.78 416.84 479.37 # 54056 100.03 95.03 109.28 53250 407.22 386.86 444.89 54057 140.63 133.60 153.64 53260 203.05 192.90 221.84 # 54057 93.41 88.74 102.05 # 53260 178.69 169.76 195.22 54060 189.41 179.94 206.93 53265 226.30 214.99 247.24 # 54060 129.83 123.34 141.84 # 53265 188.07 178.67 205.47 54065 207.09 196.74 226.25 53270 206.35 196.03 225.43 # 54065 158.74 150.80 173.42 # 53270 183.49 174.32 200.47 54100 190.86 181.32 208.52 53275 271.75 258.16 296.88 # 54100 117.78 111.89 128.67 53400 818.45 777.53 894.16 54105 285.15 270.89 311.52 53405 901.12 856.06 984.47 # 54105 220.70 209.67 241.12 53410 1,005.70 955.42 1,098.73 54110 638.36 606.44 697.41 53415 1,158.96 1,101.01 1,266.16 54111 824.05 782.85 900.28 53420 822.62 781.49 898.71 54112 967.25 918.89 1,056.72 53425 968.55 920.12 1,058.14 54115 462.24 439.13 505.00 53430 965.01 916.76 1,054.27 # 54115 430.76 409.22 470.60 53431 1,184.44 1,125.22 1,294.00 54120 646.19 613.88 705.96 53440 898.65 853.72 981.78 54125 831.56 789.98 908.48 53442 792.02 752.42 865.28 54130 1,229.23 1,167.77 1,342.94 53444 816.55 775.72 892.08 54135 1,559.83 1,481.84 1,704.12 53445 902.70 857.57 986.21 54150 173.49 164.82 189.54 53446 660.33 627.31 721.41 # 54150 99.30 94.34 108.49 53447 834.20 792.49 911.36 54160 240.98 228.93 263.27 53448 1,316.58 1,250.75 1,438.36 # 54160 148.42 141.00 162.15 53449 627.71 596.32 685.77 54161 201.93 191.83 220.60 53450 418.23 397.32 456.92 54162 278.82 264.88 304.61 53460 469.36 445.89 512.77 # 54162 200.88 190.84 219.47 53500 752.73 715.09 822.35 54163 223.36 212.19 244.02 53502 495.37 470.60 541.19 54164 196.96 187.11 215.18 53505 498.54 473.61 544.65 54200 114.11 108.40 124.66 53510 648.01 615.61 707.95 # 54200 86.75 82.41 94.77 53515 815.34 774.57 890.76 54205 550.00 522.50 600.88 53520 569.23 540.77 621.89 54220 220.15 209.14 240.51 53600 88.98 84.53 97.21 # 54220 138.45 131.53 151.26 # 53600 66.50 63.18 72.66 54230 100.79 95.75 110.11 53601 87.10 82.75 95.16 # 54230 82.43 78.31 90.06 # 53601 55.62 52.84 60.77 54231 145.57 138.29 159.03 53605 66.78 63.44 72.96 # 54231 121.21 115.15 132.42 53620 127.71 121.32 139.52 54235 93.34 88.67 101.97 # 53620 90.61 86.08 98.99 # 54235 75.73 71.94 82.73 53621 121.18 115.12 132.39 54240 104.42 99.20 114.08 # 53621 75.09 71.34 82.04 54240 TC 35.85 34.06 39.17 53660 75.91 72.11 82.93 54240 26 68.57 65.14 74.91 # 53660 42.55 40.42 46.48 54250 129.16 122.70 141.11 53661 75.52 71.74 82.50 54250 TC 12.70 12.07 13.88 # 53661 41.79 39.70 45.66 54250 26 116.46 110.64 127.24 53665 38.90 36.96 42.50 54300 665.61 632.33 727.18 53850 2,622.12 2,491.01 2,864.66 54304 779.36 740.39 851.45 # 53850 582.08 552.98 635.93 54308 742.14 705.03 810.78 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 46 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 54312 855.60 812.82 934.74 55040 343.96 326.76 375.77 54316 1,036.36 984.54 1,132.22 55041 517.17 491.31 565.01 54318 744.11 706.90 812.94 55060 384.75 365.51 420.34 54322 811.27 770.71 886.32 55100 222.05 210.95 242.59 54324 1,007.80 957.41 1,101.02 # 55100 163.96 155.76 179.12 54326 945.46 898.19 1,032.92 55110 391.50 371.93 427.72 54328 961.09 913.04 1,050.00 55120 359.46 341.49 392.71 54332 1,049.78 997.29 1,146.88 55150 495.71 470.92 541.56 54336 1,182.20 1,123.09 1,291.55 55175 369.03 350.58 403.17 54340 578.23 549.32 631.72 55180 698.64 663.71 763.27 54344 991.92 942.32 1,083.67 55200 508.06 482.66 555.06 54348 1,055.80 1,003.01 1,153.46 # 55200 282.09 267.99 308.19 54352 1,483.43 1,409.26 1,620.65 55250 449.92 427.42 491.53 54360 747.92 710.52 817.10 # 55250 232.20 220.59 253.68 54380 828.79 787.35 905.45 55300 184.73 175.49 201.81 54385 1,005.31 955.04 1,098.30 55400 516.55 490.72 564.33 54390 1,210.27 1,149.76 1,322.22 55450 394.39 374.67 430.87 54400 547.98 520.58 598.67 # 55450 260.61 247.58 284.72 54401 672.62 638.99 734.84 55500 380.53 361.50 415.73 54405 831.99 790.39 908.95 55520 389.24 369.78 425.25 54406 750.34 712.82 819.74 55530 360.74 342.70 394.11 54408 808.10 767.70 882.86 55535 436.30 414.49 476.66 54410 886.09 841.79 968.06 55540 471.04 447.49 514.61 54411 1,048.93 996.48 1,145.95 55550 430.83 409.29 470.68 54415 540.34 513.32 590.32 55600 434.55 412.82 474.74 54416 723.86 687.67 790.82 55605 513.03 487.38 560.49 54417 920.20 874.19 1,005.32 55650 729.57 693.09 797.05 54420 727.73 691.34 795.04 55680 345.85 328.56 377.84 54430 659.90 626.91 720.95 55700 239.53 227.55 261.68 54435 428.29 406.88 467.91 # 55700 140.60 133.57 153.61 54450 75.45 71.68 82.43 55705 276.57 262.74 302.15 # 54450 60.46 57.44 66.06 55706 392.82 373.18 429.16 54500 77.77 73.88 84.96 55720 470.46 446.94 513.98 54505 218.84 207.90 239.09 55725 601.06 571.01 656.66 54512 548.29 520.88 599.01 55801 1,114.06 1,058.36 1,217.11 54520 332.21 315.60 362.94 55810 1,346.99 1,279.64 1,471.59 54522 593.38 563.71 648.27 55812 1,654.71 1,571.97 1,807.77 54530 519.01 493.06 567.02 55815 1,815.41 1,724.64 1,983.34 54535 751.42 713.85 820.93 55821 897.20 852.34 980.19 54550 500.28 475.27 546.56 55831 972.01 923.41 1,061.92 54560 679.80 645.81 742.68 55840 1,375.20 1,306.44 1,502.41 54600 463.31 440.14 506.16 55842 1,473.51 1,399.83 1,609.80 54620 310.68 295.15 339.42 55845 1,684.31 1,600.09 1,840.10 54640 475.59 451.81 519.58 55860 899.88 854.89 983.12 54650 724.97 688.72 792.03 55862 1,135.29 1,078.53 1,240.31 54660 363.64 345.46 397.28 55865 1,376.36 1,307.54 1,503.67 54670 414.17 393.46 452.48 55866 1,789.88 1,700.39 1,955.45 54680 800.57 760.54 874.62 55870 181.16 172.10 197.92 54690 644.84 612.60 704.49 # 55870 148.56 141.13 162.30 54692 789.79 750.30 862.85 55873 1,173.04 1,114.39 1,281.55 54700 215.67 204.89 235.62 55875 781.55 742.47 853.84 54800 135.46 128.69 147.99 55876 145.38 138.11 158.83 54830 377.37 358.50 412.28 # 55876 108.28 102.87 118.30 54840 331.21 314.65 361.85 55920 437.54 415.66 478.01 54860 427.68 406.30 467.25 56405 101.21 96.15 110.57 54861 577.50 548.63 630.92 # 56405 98.96 94.01 108.11 54865 364.43 346.21 398.14 56420 117.60 111.72 128.48 54900 771.05 732.50 842.38 # 56420 85.37 81.10 93.27 54901 1,096.60 1,041.77 1,198.04 56440 169.90 161.41 185.62 55000 125.36 119.09 136.95 56441 140.68 133.65 153.70 # 55000 86.38 82.06 94.37 # 56441 132.81 126.17 145.10 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 47 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 56442 45.72 43.43 49.94 57200 275.86 262.07 301.38 56501 121.86 115.77 133.14 57210 341.17 324.11 372.73 # 56501 105.37 100.10 115.12 57220 297.08 282.23 324.56 56515 206.96 196.61 226.10 57230 371.98 353.38 406.39 # 56515 182.23 173.12 199.09 57240 618.95 588.00 676.20 56605 78.19 74.28 85.42 57250 604.46 574.24 660.38 # 56605 56.45 53.63 61.67 57260 751.80 714.21 821.34 56606 35.99 34.19 39.32 57265 838.34 796.42 915.88 # 56606 27.75 26.36 30.31 57267 250.75 238.21 273.94 56620 457.71 434.82 500.04 57268 447.09 424.74 488.45 56625 549.92 522.42 600.78 57270 739.42 702.45 807.82 56630 802.75 762.61 877.00 57280 899.48 854.51 982.69 56631 1,020.60 969.57 1,115.01 57282 472.88 449.24 516.63 56632 1,181.21 1,122.15 1,290.47 57283 639.63 607.65 698.80 56633 1,046.24 993.93 1,143.02 57284 780.27 741.26 852.45 56634 1,104.94 1,049.69 1,207.14 57285 626.84 595.50 684.83 56637 1,304.75 1,239.51 1,425.44 57287 660.22 627.21 721.29 56640 1,298.44 1,233.52 1,418.55 57288 691.66 657.08 755.64 56700 172.70 164.07 188.68 57289 726.29 689.98 793.48 56740 274.59 260.86 299.99 57291 504.13 478.92 550.76 56800 226.31 214.99 247.24 57292 768.97 730.52 840.10 56805 1,062.54 1,009.41 1,160.82 57295 458.45 435.53 500.86 56810 242.75 230.61 265.20 57296 879.47 835.50 960.83 56820 103.57 98.39 113.15 57300 492.95 468.30 538.55 # 56820 78.83 74.89 86.12 57305 819.43 778.46 895.23 56821 138.43 131.51 151.24 57307 916.20 870.39 1,000.95 # 56821 106.96 101.61 116.85 57308 586.96 557.61 641.25 57000 177.46 168.59 193.88 57310 463.42 440.25 506.29 57010 398.82 378.88 435.71 57311 528.31 501.89 577.17 57020 87.83 83.44 95.96 57320 526.02 499.72 574.68 # 57020 75.84 72.05 82.86 57330 744.94 707.69 813.84 57022 154.55 146.82 168.84 57335 1,081.40 1,027.33 1,181.43 57023 288.74 274.30 315.45 57400 126.30 119.99 137.99 57061 106.39 101.07 116.23 57410 99.47 94.50 108.68 # 57061 90.27 85.76 98.62 57415 148.96 141.51 162.74 57065 179.09 170.14 195.66 57420 108.84 103.40 118.91 # 57065 158.48 150.56 173.14 # 57420 83.73 79.54 91.47 57100 82.71 78.57 90.36 57421 146.43 139.11 159.98 # 57100 60.98 57.93 66.62 # 57421 114.20 108.49 124.76 57105 126.84 120.50 138.58 57423 859.75 816.76 939.27 # 57105 116.34 110.52 127.10 57425 906.37 861.05 990.21 57106 440.26 418.25 480.99 57452 102.44 97.32 111.92 57107 1,293.67 1,228.99 1,413.34 # 57452 85.58 81.30 93.50 57109 1,477.25 1,403.39 1,613.90 57454 144.16 136.95 157.49 57110 833.64 791.96 910.75 # 57454 127.30 120.94 139.08 57111 1,494.19 1,419.48 1,632.40 57455 134.60 127.87 147.05 57112 1,588.10 1,508.70 1,735.01 # 57455 103.50 98.33 113.08 57120 474.74 451.00 518.65 57456 127.35 120.98 139.13 57130 168.91 160.46 184.53 # 57456 96.62 91.79 105.56 # 57130 149.79 142.30 163.65 57460 282.73 268.59 308.88 57135 180.89 171.85 197.63 # 57460 152.70 145.07 166.83 # 57135 161.41 153.34 176.34 57461 316.41 300.59 345.68 57150 47.98 45.58 52.42 # 57461 175.88 167.09 192.15 # 57150 27.75 26.36 30.31 57500 125.47 119.20 137.08 57155 395.95 376.15 432.57 # 57500 69.64 66.16 76.08 57160 72.74 69.10 79.47 57505 95.13 90.37 103.93 # 57160 44.63 42.40 48.76 # 57505 84.64 80.41 92.47 57170 65.01 61.76 71.02 57510 124.07 117.87 135.55 # 57170 45.15 42.89 49.32 # 57510 107.96 102.56 117.94 57180 133.57 126.89 145.92 57511 135.66 128.88 148.21 # 57180 99.47 94.50 108.68 # 57511 122.17 116.06 133.47 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 48 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 57513 133.79 127.10 146.17 58353 1,100.86 1,045.82 1,202.69 # 57513 122.92 116.77 134.29 # 58353 204.87 194.63 223.82 57520 287.25 272.89 313.82 58356 2,017.40 1,916.53 2,204.01 # 57520 253.52 240.84 276.97 # 58356 323.99 307.79 353.96 57522 245.69 233.41 268.42 58400 415.90 395.11 454.38 # 57522 225.08 213.83 245.90 58410 741.61 704.53 810.21 57530 319.01 303.06 348.52 58520 723.66 687.48 790.60 57531 1,569.83 1,491.34 1,715.04 58540 839.40 797.43 917.04 57540 720.14 684.13 786.75 58541 792.19 752.58 865.47 57545 759.97 721.97 830.27 58542 880.80 836.76 962.27 57550 377.12 358.26 412.00 58543 895.27 850.51 978.09 57555 554.80 527.06 606.12 58544 967.02 918.67 1,056.47 57556 531.05 504.50 580.18 58545 826.34 785.02 902.77 57558 116.75 110.91 127.55 58546 1,046.34 994.02 1,143.12 # 57558 105.13 99.87 114.85 58548 1,631.38 1,549.81 1,782.28 57700 285.32 271.05 311.71 58550 816.82 775.98 892.38 57720 284.34 270.12 310.64 58552 902.33 857.21 985.79 57800 56.63 53.80 61.87 58553 1,051.80 999.21 1,149.09 # 57800 45.38 43.11 49.58 58554 1,208.18 1,147.77 1,319.94 58100 103.15 97.99 112.69 58555 225.32 214.05 246.16 # 58100 81.79 77.70 89.36 # 58555 177.36 168.49 193.76 58110 45.76 43.47 49.99 58558 303.74 288.55 331.83 # 58110 38.64 36.71 42.22 # 58558 249.78 237.29 272.88 58120 232.73 221.09 254.25 58559 321.06 305.01 350.76 # 58120 199.75 189.76 218.22 58560 362.78 344.64 396.34 58140 843.16 801.00 921.15 58561 513.12 487.46 560.58 58145 501.79 476.70 548.21 58562 320.58 304.55 350.23 58146 1,073.47 1,019.80 1,172.77 # 58562 272.24 258.63 297.42 58150 914.22 868.51 998.79 58563 1,791.14 1,701.58 1,956.82 58152 1,152.94 1,095.29 1,259.58 # 58563 321.06 305.01 350.76 58180 879.12 835.16 960.43 58565 1,900.42 1,805.40 2,076.21 58200 1,207.41 1,147.04 1,319.10 # 58565 408.99 388.54 446.82 58210 1,608.29 1,527.88 1,757.06 58570 850.20 807.69 928.84 58240 2,535.84 2,409.05 2,770.41 58571 935.17 888.41 1,021.67 58260 764.15 725.94 834.83 58572 1,055.92 1,003.12 1,153.59 58262 853.15 810.49 932.06 58573 1,197.32 1,137.45 1,308.07 58263 919.04 873.09 1,004.05 58600 336.27 319.46 367.38 58267 976.41 927.59 1,066.73 58605 305.98 290.68 334.28 58270 817.78 776.89 893.42 58611 72.53 68.90 79.24 58275 910.20 864.69 994.39 58615 231.29 219.73 252.69 58280 973.45 924.78 1,063.50 58660 620.91 589.86 678.34 58285 1,219.39 1,158.42 1,332.18 58661 596.26 566.45 651.42 58290 1,068.57 1,015.14 1,167.41 58662 653.25 620.59 713.68 58291 1,160.95 1,102.90 1,268.34 58670 338.68 321.75 370.01 58292 1,223.09 1,161.94 1,336.23 58671 338.47 321.55 369.78 58293 1,269.63 1,206.15 1,387.07 58672 686.43 652.11 749.93 58294 1,128.77 1,072.33 1,233.18 58673 746.87 709.53 815.96 58301 90.27 85.76 98.62 58700 704.10 668.90 769.24 # 58301 63.29 60.13 69.15 58720 661.95 628.85 723.18 58321 74.19 70.48 81.05 58740 806.78 766.44 881.41 # 58321 46.46 44.14 50.76 58750 838.97 797.02 916.57 58322 82.31 78.19 89.92 58752 845.80 803.51 924.04 # 58322 54.96 52.21 60.04 58760 758.85 720.91 829.05 58323 18.16 17.25 19.84 58770 778.03 739.13 850.00 # 58323 11.79 11.20 12.88 58800 298.32 283.40 325.91 58340 122.80 116.66 134.16 # 58800 276.96 263.11 302.58 # 58340 55.72 52.93 60.87 58805 375.06 356.31 409.76 58345 259.20 246.24 283.18 58820 290.34 275.82 317.19 58346 424.51 403.28 463.77 58822 653.02 620.37 713.43 58350 90.86 86.32 99.27 58823 884.00 839.80 965.77 # 58350 72.87 69.23 79.61 # 58823 172.39 163.77 188.34 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 49 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 58825 643.71 611.52 703.25 59412 94.57 89.84 103.32 58900 382.69 363.56 418.09 59414 83.51 79.33 91.23 58920 647.17 614.81 707.03 59425 404.09 383.89 441.47 58925 675.42 641.65 737.90 # 59425 311.53 295.95 340.34 58940 463.54 440.36 506.41 59426 723.83 687.64 790.79 58943 1,030.61 979.08 1,125.94 # 59426 551.46 523.89 602.47 58950 983.93 934.73 1,074.94 59430 127.87 121.48 139.70 58951 1,268.00 1,204.60 1,385.29 # 59430 114.76 109.02 125.37 58952 1,429.91 1,358.41 1,562.17 59510 1,822.33 1,731.21 1,990.89 58953 1,772.57 1,683.94 1,936.53 59514 829.69 788.21 906.44 58954 1,923.91 1,827.71 2,101.87 59515 983.71 934.52 1,074.70 58956 1,233.73 1,172.04 1,347.85 59525 442.07 419.97 482.97 58957 1,364.53 1,296.30 1,490.75 59610 1,694.21 1,609.50 1,850.93 58958 1,516.25 1,440.44 1,656.51 59612 785.13 745.87 857.75 58960 850.34 807.82 928.99 59614 881.26 837.20 962.78 58970 209.07 198.62 228.41 59618 1,905.75 1,810.46 2,082.03 # 58970 185.46 176.19 202.62 59620 910.87 865.33 995.13 58976 239.66 227.68 261.83 59622 1,066.54 1,013.21 1,165.19 # 58976 208.56 198.13 227.85 59812 286.58 272.25 313.09 59000 120.63 114.60 131.79 # 59812 265.97 252.67 290.57 # 59000 74.16 70.45 81.02 59820 341.63 324.55 373.23 59001 169.49 161.02 185.17 # 59820 316.53 300.70 345.81 59012 186.07 176.77 203.29 59821 346.43 329.11 378.48 59015 143.47 136.30 156.75 # 59821 319.83 303.84 349.42 # 59015 121.36 115.29 132.58 59830 395.57 375.79 432.16 59020 65.23 61.97 71.27 59840 198.34 188.42 216.68 59020 TC 30.90 29.36 33.76 # 59840 191.59 182.01 209.31 59020 26 34.34 32.62 37.51 59841 344.09 326.89 375.92 59025 43.35 41.18 47.36 # 59841 323.48 307.31 353.41 59025 TC 15.70 14.92 17.16 59850 354.04 336.34 386.79 59025 26 27.65 26.27 30.21 59851 364.13 345.92 397.81 59030 103.21 98.05 112.76 59852 511.36 485.79 558.66 59050 46.09 43.79 50.36 59855 376.80 357.96 411.65 59051 38.14 36.23 41.66 59856 443.89 421.70 484.96 59070 373.53 354.85 408.08 59857 532.09 505.49 581.31 # 59070 272.72 259.08 297.94 59866 219.11 208.15 239.37 59072 450.94 428.39 492.65 59870 427.99 406.59 467.58 59074 353.29 335.63 385.97 59871 122.63 116.50 133.98 # 59074 270.10 256.60 295.09 60000 146.52 139.19 160.07 59076 440.45 418.43 481.19 # 60000 133.40 126.73 145.74 59100 747.74 710.35 816.90 60100 109.27 103.81 119.38 59120 715.46 679.69 781.64 # 60100 78.92 74.97 86.22 59121 718.22 682.31 784.66 60200 589.72 560.23 644.26 59130 836.59 794.76 913.97 60210 628.37 596.95 686.49 59135 848.98 806.53 927.51 60212 900.27 855.26 983.55 59136 792.00 752.40 865.26 60220 688.97 654.52 752.70 59140 357.26 339.40 390.31 60225 827.73 786.34 904.29 59150 694.49 659.77 758.74 60240 874.24 830.53 955.11 59151 678.17 644.26 740.90 60252 1,182.33 1,123.21 1,291.69 59160 196.81 186.97 215.02 60254 1,526.61 1,450.28 1,667.82 # 59160 163.84 155.65 179.00 60260 987.43 938.06 1,078.77 59200 69.13 65.67 75.52 60270 1,244.86 1,182.62 1,360.01 # 59200 41.03 38.98 44.83 60271 955.18 907.42 1,043.53 59300 177.36 168.49 193.76 60280 399.20 379.24 436.13 # 59300 133.52 126.84 145.87 60281 531.66 505.08 580.84 59320 140.12 133.11 153.08 60300 103.60 98.42 113.18 59325 221.05 210.00 241.50 # 60300 48.52 46.09 53.00 59350 252.38 239.76 275.72 60500 906.00 860.70 989.81 59400 1,609.46 1,528.99 1,758.34 60502 1,136.97 1,080.12 1,242.14 59409 700.59 665.56 765.39 60505 1,250.42 1,187.90 1,366.09 59410 815.84 775.05 891.31 60512 220.68 209.65 241.10 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 50 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 60520 932.61 885.98 1,018.88 61519 2,555.75 2,427.96 2,792.15 60521 1,069.36 1,015.89 1,168.27 61520 3,284.50 3,120.28 3,588.32 60522 1,290.08 1,225.58 1,409.42 61521 2,745.90 2,608.61 2,999.90 60540 988.76 939.32 1,080.22 61522 1,886.75 1,792.41 2,061.27 60545 1,123.20 1,067.04 1,227.10 61524 1,781.35 1,692.28 1,946.12 60600 1,305.20 1,239.94 1,425.93 61526 3,004.62 2,854.39 3,282.55 60605 1,643.04 1,560.89 1,795.02 61530 2,551.53 2,423.95 2,787.54 60650 1,096.99 1,042.14 1,198.46 61531 1,037.41 985.54 1,133.37 61000 101.50 96.43 110.89 61533 1,305.37 1,240.10 1,426.12 61001 99.12 94.16 108.28 61534 1,407.12 1,336.76 1,537.27 61020 117.46 111.59 128.33 61535 845.51 803.23 923.71 61026 117.04 111.19 127.87 61536 2,236.56 2,124.73 2,443.44 61050 101.26 96.20 110.63 61537 2,069.70 1,966.22 2,261.15 61055 129.91 123.41 141.92 61538 2,222.49 2,111.37 2,428.08 61070 75.40 71.63 82.37 61539 2,024.59 1,923.36 2,211.86 61105 383.51 364.33 418.98 61540 1,896.32 1,801.50 2,071.73 61107 279.79 265.80 305.67 61541 1,830.88 1,739.34 2,000.24 61108 760.03 722.03 830.33 61542 1,979.74 1,880.75 2,162.86 61120 623.42 592.25 681.09 61543 1,848.22 1,755.81 2,019.18 61140 1,076.23 1,022.42 1,175.78 61544 1,524.46 1,448.24 1,665.48 61150 1,151.37 1,093.80 1,257.87 61545 2,726.60 2,590.27 2,978.81 61151 835.09 793.34 912.34 61546 1,976.72 1,877.88 2,159.56 61154 1,077.99 1,024.09 1,177.70 61548 1,355.10 1,287.35 1,480.45 61156 1,073.19 1,019.53 1,172.46 61550 898.84 853.90 981.99 61210 326.70 310.37 356.93 61552 1,182.67 1,123.54 1,292.07 61215 418.71 397.77 457.44 61556 1,416.37 1,345.55 1,547.38 61250 726.36 690.04 793.55 61557 1,451.70 1,379.12 1,585.99 61253 801.99 761.89 876.17 61558 1,529.87 1,453.38 1,671.39 61304 1,415.30 1,344.54 1,546.22 61559 2,073.94 1,970.24 2,265.78 61305 1,711.69 1,626.11 1,870.03 61563 1,679.35 1,595.38 1,834.69 61312 1,774.33 1,685.61 1,938.45 61564 2,084.85 1,980.61 2,277.70 61313 1,694.51 1,609.78 1,851.25 61566 1,933.35 1,836.68 2,112.18 61314 1,565.82 1,487.53 1,710.66 61567 2,184.88 2,075.64 2,386.99 61315 1,782.06 1,692.96 1,946.90 61570 1,580.03 1,501.03 1,726.18 61316 76.95 73.10 84.07 61571 1,713.55 1,627.87 1,872.05 61320 1,648.00 1,565.60 1,800.44 61575 2,060.17 1,957.16 2,250.73 61321 1,806.35 1,716.03 1,973.43 61576 3,325.09 3,158.84 3,632.67 61322 2,007.20 1,906.84 2,192.87 61580 2,191.41 2,081.84 2,394.12 61323 2,039.27 1,937.31 2,227.91 61581 2,458.38 2,335.46 2,685.78 61330 1,423.11 1,351.95 1,554.74 61582 2,503.02 2,377.87 2,734.55 61332 1,631.88 1,550.29 1,782.83 61583 2,509.71 2,384.22 2,741.85 61333 1,656.25 1,573.44 1,809.46 61584 2,450.58 2,328.05 2,677.26 61334 1,080.58 1,026.55 1,180.53 61585 2,606.72 2,476.38 2,847.84 61340 1,228.79 1,167.35 1,342.45 61586 1,889.74 1,795.25 2,064.54 61343 1,895.63 1,800.85 2,070.98 61590 2,775.33 2,636.56 3,032.04 61345 1,755.17 1,667.41 1,917.52 61591 2,792.78 2,653.14 3,051.11 61440 1,718.04 1,632.14 1,876.96 61592 2,749.95 2,612.45 3,004.32 61450 1,632.67 1,551.04 1,783.70 61595 2,103.36 1,998.19 2,297.92 61458 1,734.94 1,648.19 1,895.42 61596 2,316.45 2,200.63 2,530.72 61460 1,765.94 1,677.64 1,929.29 61597 2,492.79 2,368.15 2,723.37 61470 1,637.22 1,555.36 1,788.66 61598 2,229.20 2,117.74 2,435.40 61480 1,580.00 1,501.00 1,726.15 61600 1,892.97 1,798.32 2,068.07 61490 1,639.79 1,557.80 1,791.47 61601 2,048.77 1,946.33 2,238.28 61500 1,166.26 1,107.95 1,274.14 61605 1,989.66 1,890.18 2,173.71 61501 1,002.52 952.39 1,095.25 61606 2,620.29 2,489.28 2,862.67 61510 1,873.98 1,780.28 2,047.32 61607 2,438.98 2,317.03 2,664.58 61512 2,207.14 2,096.78 2,411.30 61608 2,816.64 2,675.81 3,077.18 61514 1,640.61 1,558.58 1,792.37 61609 537.65 510.77 587.39 61516 1,600.88 1,520.84 1,748.97 61610 1,650.42 1,567.90 1,803.09 61517 76.96 73.11 84.08 61611 417.16 396.30 455.75 61518 2,376.22 2,257.41 2,596.02 61612 1,485.87 1,411.58 1,623.32 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 51 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 61613 2,753.92 2,616.22 3,008.65 62141 990.88 941.34 1,082.54 61615 2,195.02 2,085.27 2,398.06 62142 757.09 719.24 827.13 61616 2,864.21 2,721.00 3,129.15 62143 884.78 840.54 966.62 61618 1,127.45 1,071.08 1,231.74 62145 1,212.28 1,151.67 1,324.42 61619 1,301.83 1,236.74 1,422.25 62146 1,042.31 990.19 1,138.72 61623 526.25 499.94 574.93 62147 1,237.32 1,175.45 1,351.77 61624 1,047.99 995.59 1,144.93 62148 110.11 104.60 120.29 61626 856.57 813.74 935.80 62160 168.62 160.19 184.22 61630 1,197.26 1,137.40 1,308.01 62161 1,301.66 1,236.58 1,422.07 61635 1,310.86 1,245.32 1,432.12 62162 1,622.47 1,541.35 1,772.55 61680 1,954.18 1,856.47 2,134.94 62163 1,050.65 998.12 1,147.84 61682 3,659.77 3,476.78 3,998.30 62164 1,736.27 1,649.46 1,896.88 61684 2,439.77 2,317.78 2,665.45 62165 1,356.58 1,288.75 1,482.06 61686 3,921.69 3,725.61 4,284.45 62180 1,367.09 1,298.74 1,493.55 61690 1,864.12 1,770.91 2,036.55 62190 779.52 740.54 851.62 61692 3,167.93 3,009.53 3,460.96 62192 829.86 788.37 906.63 61697 3,599.71 3,419.72 3,932.68 62194 340.85 323.81 372.38 61698 3,882.57 3,688.44 4,241.71 62200 1,179.93 1,120.93 1,289.07 61700 2,993.59 2,843.91 3,270.50 62201 1,016.64 965.81 1,110.68 61702 3,380.87 3,211.83 3,693.60 62220 870.28 826.77 950.79 61703 1,158.42 1,100.50 1,265.58 62223 896.90 852.06 979.87 61705 2,209.00 2,098.55 2,413.33 62225 429.77 408.28 469.52 61708 1,948.78 1,851.34 2,129.04 62230 720.20 684.19 786.82 61710 1,757.08 1,669.23 1,919.61 62252 92.02 87.42 100.53 61711 2,248.71 2,136.27 2,456.71 62252 TC 50.55 48.02 55.22 61720 1,015.26 964.50 1,109.18 62252 26 41.47 39.40 45.31 61735 1,251.60 1,189.02 1,367.37 62256 502.55 477.42 549.03 61750 1,206.94 1,146.59 1,318.58 62258 967.17 918.81 1,056.63 61751 1,177.71 1,118.82 1,286.64 62263 603.01 572.86 658.79 61760 1,325.25 1,258.99 1,447.84 # 62263 348.94 331.49 381.21 61770 1,321.75 1,255.66 1,444.01 62264 368.14 349.73 402.19 61790 731.94 695.34 799.64 # 62264 212.25 201.64 231.89 61791 949.09 901.64 1,036.89 62267 238.69 226.76 260.77 61795 220.34 209.32 240.72 # 62267 155.13 147.37 169.48 61796 689.84 655.35 753.65 62268 436.33 414.51 476.69 61797 187.72 178.33 205.08 # 62268 250.46 237.94 273.63 61798 689.84 655.35 753.65 62269 474.28 450.57 518.16 61799 259.47 246.50 283.48 # 62269 255.06 242.31 278.66 61800 132.24 125.63 144.47 62270 145.55 138.27 159.01 61850 841.43 799.36 919.26 # 62270 72.85 69.21 79.59 61860 1,340.39 1,273.37 1,464.38 62272 171.23 162.67 187.07 61863 1,297.05 1,232.20 1,417.03 # 62272 76.42 72.60 83.49 61864 323.62 307.44 353.56 62273 153.16 145.50 167.33 61867 1,929.51 1,833.03 2,107.98 # 62273 103.32 98.15 112.87 61868 500.93 475.88 547.26 62280 284.97 270.72 311.33 61870 1,019.32 968.35 1,113.60 # 62280 141.07 134.02 154.12 61875 998.95 949.00 1,091.35 62281 264.36 251.14 288.81 61880 471.80 448.21 515.44 # 62281 136.58 129.75 149.21 61885 549.75 522.26 600.60 62282 274.98 261.23 300.41 61886 692.91 658.26 757.00 # 62282 126.21 119.90 137.89 61888 343.49 326.32 375.27 62284 210.22 199.71 229.67 62000 769.78 731.29 840.98 # 62284 85.44 81.17 93.35 62005 1,068.09 1,014.69 1,166.89 62287 506.06 480.76 552.87 62010 1,301.30 1,236.24 1,421.68 62290 305.02 289.77 333.24 62100 1,389.65 1,320.17 1,518.20 # 62290 158.87 150.93 173.57 62115 1,221.91 1,160.81 1,334.93 62291 285.04 270.79 311.41 62116 1,525.62 1,449.34 1,666.74 # 62291 153.13 145.47 167.29 62117 1,662.07 1,578.97 1,815.82 62292 450.86 428.32 492.57 62120 1,597.05 1,517.20 1,744.78 62294 728.18 691.77 795.54 62121 1,444.35 1,372.13 1,577.95 62310 201.67 191.59 220.33 62140 902.00 856.90 985.44 # 62310 93.75 89.06 102.42 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 52 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 62311 178.46 169.54 194.97 63180 1,209.45 1,148.98 1,321.33 # 62311 78.03 74.13 85.25 63182 1,284.35 1,220.13 1,403.15 62318 215.73 204.94 235.68 63185 988.58 939.15 1,080.02 # 62318 93.94 89.24 102.63 63190 1,136.22 1,079.41 1,241.32 62319 195.19 185.43 213.24 63191 1,053.47 1,000.80 1,150.92 # 62319 88.01 83.61 96.15 63194 1,293.93 1,229.23 1,413.61 62350 349.19 331.73 381.49 63195 1,297.37 1,232.50 1,417.38 62351 737.00 700.15 805.17 63196 1,526.53 1,450.20 1,667.73 62355 262.85 249.71 287.17 63197 1,456.33 1,383.51 1,591.04 62360 255.59 242.81 279.23 63198 1,604.28 1,524.07 1,752.68 62361 350.21 332.70 382.61 63199 1,748.38 1,660.96 1,910.10 62362 366.40 348.08 400.29 63200 1,301.45 1,236.38 1,421.84 62365 290.41 275.89 317.27 63250 2,524.88 2,398.64 2,758.44 62367 35.80 34.01 39.11 63251 2,613.09 2,482.44 2,854.81 # 62367 22.31 21.19 24.37 63252 2,613.19 2,482.53 2,854.91 62368 50.91 48.36 55.61 63265 1,441.37 1,369.30 1,574.70 # 62368 34.79 33.05 38.01 63266 1,481.72 1,407.63 1,618.77 63001 1,066.08 1,012.78 1,164.70 63267 1,195.49 1,135.72 1,306.08 63003 1,073.10 1,019.45 1,172.37 63268 1,205.09 1,144.84 1,316.57 63005 1,021.46 970.39 1,115.95 63270 1,771.65 1,683.07 1,935.53 63011 962.71 914.57 1,051.76 63271 1,782.18 1,693.07 1,947.03 63012 1,038.17 986.26 1,134.20 63272 1,643.56 1,561.38 1,795.59 63015 1,279.32 1,215.35 1,397.65 63273 1,551.86 1,474.27 1,695.41 63016 1,317.14 1,251.28 1,438.97 63275 1,547.72 1,470.33 1,690.88 63017 1,076.37 1,022.55 1,175.93 63276 1,541.72 1,464.63 1,684.32 63020 1,016.34 965.52 1,110.35 63277 1,354.70 1,286.97 1,480.02 63030 845.74 803.45 923.97 63278 1,328.88 1,262.44 1,451.81 63035 177.74 168.85 194.18 63280 1,827.20 1,735.84 1,996.22 63040 1,231.88 1,170.29 1,345.83 63281 1,806.47 1,716.15 1,973.57 63042 1,155.14 1,097.38 1,261.99 63282 1,705.17 1,619.91 1,862.90 63043 389.76 370.27 425.81 63283 1,616.73 1,535.89 1,766.27 63044 354.43 336.71 387.22 63285 2,238.37 2,126.45 2,445.42 63045 1,103.78 1,048.59 1,205.88 63286 2,230.86 2,119.32 2,437.22 63046 1,057.13 1,004.27 1,154.91 63287 2,355.56 2,237.78 2,573.45 63047 965.66 917.38 1,054.99 63290 2,386.95 2,267.60 2,607.74 63048 192.23 182.62 210.01 63295 283.71 269.52 309.95 63050 1,326.75 1,260.41 1,449.47 63300 1,595.70 1,515.92 1,743.31 63051 1,502.45 1,427.33 1,641.43 63301 1,797.45 1,707.58 1,963.72 63055 1,418.10 1,347.20 1,549.28 63302 1,785.38 1,696.11 1,950.53 63056 1,310.47 1,244.95 1,431.69 63303 1,873.70 1,780.02 2,047.02 63057 293.62 278.94 320.78 63304 1,980.62 1,881.59 2,163.83 63064 1,550.63 1,473.10 1,694.07 63305 2,024.80 1,923.56 2,212.09 63066 181.54 172.46 198.33 63306 2,111.02 2,005.47 2,306.29 63075 1,210.68 1,150.15 1,322.67 63307 1,980.12 1,881.11 2,163.28 63076 226.53 215.20 247.48 63308 293.67 278.99 320.84 63077 1,334.43 1,267.71 1,457.87 63600 745.79 708.50 814.78 63078 181.01 171.96 197.75 63610 1,253.67 1,190.99 1,369.64 63081 1,556.54 1,478.71 1,700.52 # 63610 397.41 377.54 434.17 63082 244.70 232.47 267.34 63615 1,002.44 952.32 1,095.17 63085 1,673.75 1,590.06 1,828.57 63620 689.84 655.35 753.65 63086 174.72 165.98 190.88 63621 215.81 205.02 235.77 63087 2,133.07 2,026.42 2,330.38 63650 372.76 354.12 407.24 63088 239.17 227.21 261.29 63655 736.95 700.10 805.12 63090 1,753.04 1,665.39 1,915.20 63660 392.68 373.05 429.01 63091 164.87 156.63 180.12 63685 354.56 336.83 387.35 63101 2,002.41 1,902.29 2,187.63 63688 318.47 302.55 347.93 63102 1,993.42 1,893.75 2,177.81 63700 1,069.09 1,015.64 1,167.99 63103 264.03 250.83 288.45 63702 1,201.52 1,141.44 1,312.66 63170 1,333.55 1,266.87 1,456.90 63704 1,337.12 1,270.26 1,460.80 63172 1,200.21 1,140.20 1,311.23 63706 1,551.58 1,474.00 1,695.10 63173 1,478.20 1,404.29 1,614.93 63707 791.08 751.53 864.26 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 53 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 63709 960.28 912.27 1,049.11 64484 126.50 120.18 138.21 63710 957.18 909.32 1,045.72 # 64484 62.79 59.65 68.60 63740 812.72 772.08 887.89 64505 93.44 88.77 102.09 63741 528.36 501.94 577.23 # 64505 77.70 73.82 84.89 63744 554.69 526.96 606.00 64508 132.25 125.64 144.49 63746 486.33 462.01 531.31 # 64508 64.42 61.20 70.38 64400 98.91 93.96 108.05 64510 131.36 124.79 143.51 # 64400 58.06 55.16 63.43 # 64510 62.41 59.29 68.18 64402 100.92 95.87 110.25 64517 156.50 148.68 170.98 # 64402 66.07 62.77 72.19 # 64517 109.66 104.18 119.81 64405 95.03 90.28 103.82 64520 172.56 163.93 188.52 # 64405 67.68 64.30 73.95 # 64520 70.63 67.10 77.17 64408 109.85 104.36 120.01 64530 177.82 168.93 194.27 # 64408 82.12 78.01 89.71 # 64530 83.38 79.21 91.09 64410 128.40 121.98 140.28 64550 14.53 13.80 15.87 # 64410 72.56 68.93 79.27 # 64550 8.53 8.10 9.32 64412 128.21 121.80 140.07 64553 186.71 177.37 203.98 # 64412 64.88 61.64 70.89 # 64553 145.49 138.22 158.95 64413 105.79 100.50 115.58 64555 198.55 188.62 216.91 # 64413 70.56 67.03 77.08 # 64555 143.09 135.94 156.33 64415 120.46 114.44 131.61 64560 196.30 186.49 214.46 # 64415 67.99 64.59 74.28 # 64560 147.21 139.85 160.83 64416 83.94 79.74 91.70 64561 1,089.40 1,034.93 1,190.17 64417 121.60 115.52 132.85 # 64561 399.89 379.90 436.89 # 64417 67.26 63.90 73.49 64565 157.05 149.20 171.58 64418 124.47 118.25 135.99 # 64565 109.46 103.99 119.59 # 64418 67.51 64.13 73.75 64573 519.59 493.61 567.65 64420 148.82 141.38 162.59 64575 256.96 244.11 280.73 # 64420 60.75 57.71 66.37 64577 317.33 301.46 346.68 64421 219.81 208.82 240.14 64580 268.86 255.42 293.73 # 64421 83.04 78.89 90.72 64581 774.79 736.05 846.46 64425 117.75 111.86 128.64 64585 314.43 298.71 343.52 # 64425 85.89 81.60 93.84 # 64585 148.80 141.36 162.56 64430 145.38 138.11 158.83 64590 294.30 279.59 321.53 # 64430 82.05 77.95 89.64 # 64590 166.52 158.19 181.92 64435 134.03 127.33 146.43 64595 305.36 290.09 333.60 # 64435 77.82 73.93 85.02 # 64595 131.49 124.92 143.66 64445 125.12 118.86 136.69 64600 371.78 353.19 406.17 # 64445 74.16 70.45 81.02 # 64600 194.53 184.80 212.52 64446 84.73 80.49 92.56 64605 519.39 493.42 567.43 64447 64.59 61.36 70.56 # 64605 307.29 291.93 335.72 64448 74.90 71.16 81.83 64610 625.93 594.63 683.82 64449 84.27 80.06 92.07 # 64610 429.20 407.74 468.90 64450 94.81 90.07 103.58 64612 141.82 134.73 154.94 # 64450 66.33 63.01 72.46 # 64612 124.21 118.00 135.70 64455 48.04 45.64 52.49 64613 139.57 132.59 152.48 # 64455 37.54 35.66 41.01 # 64613 117.09 111.24 127.93 64470 243.93 231.73 266.49 64614 156.71 148.87 171.20 # 64470 95.91 91.11 104.78 # 64614 130.48 123.96 142.55 64472 104.44 99.22 114.10 64620 249.63 237.15 272.72 # 64472 60.97 57.92 66.61 # 64620 152.20 144.59 166.28 64475 218.90 207.96 239.15 64622 300.04 285.04 327.80 # 64475 75.38 71.61 82.35 # 64622 161.76 153.67 176.72 64476 87.85 83.46 95.98 64623 111.65 106.07 121.98 # 64476 45.51 43.23 49.71 # 64623 45.32 43.05 49.51 64479 257.84 244.95 281.69 64626 348.71 331.27 380.96 # 64479 113.57 107.89 124.07 # 64626 214.18 203.47 233.99 64480 128.41 121.99 140.29 64627 152.80 145.16 166.93 # 64480 73.70 70.02 80.52 # 64627 53.12 50.46 58.03 64483 251.35 238.78 274.60 64630 214.89 204.15 234.77 # 64483 99.96 94.96 109.20 # 64630 177.79 168.90 194.24 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 54 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 64632 79.71 75.72 87.08 64823 683.99 649.79 747.26 # 64632 67.72 64.33 73.98 64831 605.16 574.90 661.14 64640 211.15 200.59 230.68 64832 314.25 298.54 343.32 # 64640 162.06 153.96 177.05 64834 667.88 634.49 729.66 64650 61.85 58.76 67.57 64835 723.54 687.36 790.46 # 64650 36.36 34.54 39.72 64836 723.67 687.49 790.61 64653 71.67 68.09 78.30 64837 348.75 331.31 381.01 # 64653 45.44 43.17 49.65 64840 826.60 785.27 903.06 64680 284.08 269.88 310.36 64856 909.71 864.22 993.85 # 64680 148.05 140.65 161.75 64857 951.00 903.45 1,038.97 64681 365.84 347.55 399.68 64858 1,090.89 1,036.35 1,191.80 # 64681 198.33 188.41 216.67 64859 236.40 224.58 258.27 64702 414.16 393.45 452.47 64861 1,226.13 1,164.82 1,339.54 64704 303.09 287.94 331.13 64862 1,197.08 1,137.23 1,307.81 64708 427.70 406.32 467.27 64864 792.58 752.95 865.89 64712 491.38 466.81 536.83 64865 1,053.29 1,000.63 1,150.72 64713 682.76 648.62 745.91 64866 1,090.65 1,036.12 1,191.54 64714 584.85 555.61 638.95 64868 956.70 908.87 1,045.20 64716 471.14 447.58 514.72 64870 929.78 883.29 1,015.78 64718 505.58 480.30 552.35 64872 111.08 105.53 121.36 64719 350.33 332.81 382.73 64874 163.19 155.03 178.28 64721 371.09 352.54 405.42 64876 177.72 168.83 194.15 # 64721 369.60 351.12 403.79 64885 1,031.93 980.33 1,127.38 64722 300.37 285.35 328.15 64886 1,223.18 1,162.02 1,336.32 64726 263.51 250.33 287.88 64890 979.85 930.86 1,070.49 64727 170.02 161.52 185.75 64891 1,016.21 965.40 1,110.21 64732 340.83 323.79 372.36 64892 951.33 903.76 1,039.32 64734 369.15 350.69 403.29 64893 1,000.78 950.74 1,093.35 64736 351.45 333.88 383.96 64895 1,176.54 1,117.71 1,285.37 64738 410.90 390.36 448.91 64896 1,296.61 1,231.78 1,416.55 64740 413.60 392.92 451.86 64897 1,139.23 1,082.27 1,244.61 64742 421.99 400.89 461.02 64898 1,242.79 1,180.65 1,357.75 64744 366.64 348.31 400.56 64901 555.59 527.81 606.98 64746 398.42 378.50 435.28 64902 638.39 606.47 697.44 64752 450.38 427.86 492.04 64905 912.53 866.90 996.94 64755 796.54 756.71 870.22 64907 1,194.37 1,134.65 1,304.85 64760 425.28 404.02 464.62 64910 734.58 697.85 802.53 64761 404.90 384.66 442.36 64911 886.46 842.14 968.46 64763 489.70 465.22 535.00 65091 534.54 507.81 583.98 64766 562.88 534.74 614.95 65093 533.66 506.98 583.03 64771 527.84 501.45 576.67 65101 616.49 585.67 673.52 64772 505.59 480.31 552.36 65103 643.42 611.25 702.94 64774 367.05 348.70 401.01 65105 709.47 674.00 775.10 64776 352.28 334.67 384.87 65110 1,030.19 978.68 1,125.48 64778 168.92 160.47 184.54 65112 1,210.22 1,149.71 1,322.17 64782 414.78 394.04 453.15 65114 1,260.16 1,197.15 1,376.72 64783 202.26 192.15 220.97 65125 387.66 368.28 423.52 64784 645.28 613.02 704.97 # 65125 242.27 230.16 264.68 64786 963.27 915.11 1,052.38 65130 609.58 579.10 665.97 64787 232.22 220.61 253.70 65135 620.74 589.70 678.16 64788 344.82 327.58 376.72 65140 676.07 642.27 738.61 64790 733.68 697.00 801.55 65150 490.55 466.02 535.92 64792 953.22 905.56 1,041.39 65155 712.43 676.81 778.33 64795 173.43 164.76 189.47 65175 549.61 522.13 600.45 64802 539.21 512.25 589.09 65205 48.22 45.81 52.68 64804 819.68 778.70 895.51 # 65205 38.10 36.20 41.63 64809 774.52 735.79 846.16 65210 59.07 56.12 64.54 64818 599.93 569.93 655.42 # 65210 45.95 43.65 50.20 64820 676.13 642.32 738.67 65220 49.30 46.84 53.87 64821 611.80 581.21 668.39 # 65220 37.31 35.44 40.76 64822 603.43 573.26 659.25 65222 64.94 61.69 70.94 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 55 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 65222 50.32 47.80 54.97 65875 522.25 496.14 570.56 65235 583.64 554.46 637.63 65880 550.08 522.58 600.97 65260 799.38 759.41 873.32 65900 806.42 766.10 881.02 65265 899.65 854.67 982.87 65920 653.03 620.38 713.44 65270 227.39 216.02 248.42 65930 536.81 509.97 586.47 # 65270 118.71 112.77 129.69 66020 157.58 149.70 172.16 65272 417.67 396.79 456.31 # 66020 109.99 104.49 120.16 # 65272 289.14 274.68 315.88 66030 139.74 132.75 152.66 65273 317.36 301.49 346.71 # 66030 92.15 87.54 100.67 65275 465.98 442.68 509.08 66130 593.14 563.48 648.00 # 65275 377.17 358.31 412.06 # 66130 482.22 458.11 526.83 65280 556.70 528.87 608.20 66150 719.20 683.24 785.73 65285 866.87 823.53 947.06 66155 717.26 681.40 783.61 65286 590.88 561.34 645.54 66160 815.06 774.31 890.46 # 65286 409.51 389.03 447.38 66165 702.87 667.73 767.89 65290 408.81 388.37 446.63 66170 987.04 937.69 1,078.34 65400 559.87 531.88 611.66 66172 1,240.50 1,178.48 1,355.25 # 65400 495.04 470.29 540.83 66180 977.84 928.95 1,068.29 65410 122.01 115.91 133.30 66185 619.32 588.35 676.60 # 65410 88.66 84.23 96.86 66220 605.22 574.96 661.20 65420 434.47 412.75 474.66 66225 776.81 737.97 848.67 # 65420 312.68 297.05 341.61 66250 628.56 597.13 686.70 65426 547.06 519.71 597.67 # 66250 459.56 436.58 502.07 # 65426 397.54 377.66 434.31 66500 295.26 280.50 322.58 65430 98.03 93.13 107.10 66505 323.17 307.01 353.06 # 65430 88.66 84.23 96.86 66600 682.01 647.91 745.10 65435 67.95 64.55 74.23 66605 882.39 838.27 964.01 # 65435 59.33 56.36 64.81 66625 358.27 340.36 391.41 65436 321.75 305.66 351.51 66630 471.09 447.54 514.67 # 65436 308.64 293.21 337.19 66635 475.83 452.04 519.85 65450 267.39 254.02 292.12 66680 426.29 404.98 465.73 # 65450 264.01 250.81 288.43 66682 519.36 493.39 567.40 65600 324.25 308.04 354.25 66700 374.61 355.88 409.26 # 65600 280.03 266.03 305.93 # 66700 328.89 312.45 359.32 65710 920.80 874.76 1,005.97 66710 368.07 349.67 402.12 65730 1,023.43 972.26 1,118.10 # 66710 327.98 311.58 358.32 65750 1,036.73 984.89 1,132.62 66711 527.04 500.69 575.79 65755 1,030.72 979.18 1,126.06 66720 386.84 367.50 422.63 65756 991.01 941.46 1,082.68 # 66720 347.87 330.48 380.05 65770 1,184.09 1,124.89 1,293.62 66740 365.45 347.18 399.26 65772 374.25 355.54 408.87 # 66740 329.48 313.01 359.96 # 65772 335.28 318.52 366.30 66761 376.09 357.29 410.88 65775 458.37 435.45 500.77 # 66761 341.24 324.18 372.81 65780 739.13 702.17 807.50 66762 393.66 373.98 430.08 65781 1,120.67 1,064.64 1,224.34 # 66762 352.07 334.47 384.64 65782 966.68 918.35 1,056.10 66770 436.98 415.13 477.40 65800 128.10 121.70 139.96 # 66770 399.13 379.17 436.05 # 65800 111.98 106.38 122.34 66820 332.27 315.66 363.01 65805 140.09 133.09 153.05 66821 269.97 256.47 294.94 # 65805 111.98 106.38 122.34 # 66821 254.23 241.52 277.75 65810 388.74 369.30 424.70 66825 635.43 603.66 694.21 65815 535.18 508.42 584.68 66830 592.91 563.26 647.75 # 65815 393.90 374.21 430.34 66840 577.70 548.82 631.14 65820 626.57 595.24 684.53 66850 659.26 626.30 720.25 65850 709.34 673.87 774.95 66852 705.18 669.92 770.41 65855 285.47 271.20 311.88 66920 629.28 597.82 687.49 # 65855 250.25 237.74 273.40 66930 715.02 679.27 781.16 65860 263.68 250.50 288.08 66940 649.81 617.32 709.92 # 65860 216.46 205.64 236.49 66982 892.37 847.75 974.91 65865 398.04 378.14 434.86 66983 617.91 587.01 675.06 65870 491.54 466.96 537.00 66984 640.96 608.91 700.25 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 56 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 66985 635.35 603.58 694.12 67320 276.37 262.55 301.93 66986 775.57 736.79 847.31 67331 261.59 248.51 285.79 66990 78.86 74.92 86.16 67332 284.56 270.33 310.88 67005 391.89 372.30 428.15 67334 258.17 245.26 282.05 67010 453.08 430.43 494.99 67335 129.82 123.33 141.83 67015 484.47 460.25 529.29 67340 307.50 292.13 335.95 67025 604.60 574.37 660.53 67343 542.74 515.60 592.94 # 67025 522.16 496.05 570.46 67345 197.62 187.74 215.90 67027 713.53 677.85 779.53 # 67345 179.26 170.30 195.85 67028 180.95 171.90 197.69 67346 171.96 163.36 187.86 # 67028 143.85 136.66 157.16 67400 783.84 744.65 856.35 67030 434.12 412.41 474.27 67405 668.07 634.67 729.87 67031 321.04 304.99 350.74 67412 725.92 689.62 793.06 # 67031 293.68 279.00 320.85 67413 726.37 690.05 793.56 67036 805.92 765.62 880.46 67414 1,108.89 1,053.45 1,211.47 67039 1,033.15 981.49 1,128.71 67415 90.83 86.29 99.23 67040 1,191.13 1,131.57 1,301.31 67420 1,380.51 1,311.48 1,508.20 67041 1,111.43 1,055.86 1,214.24 67430 1,052.24 999.63 1,149.57 67042 1,272.36 1,208.74 1,390.05 67440 1,015.33 964.56 1,109.24 67043 1,335.60 1,268.82 1,459.14 67445 1,188.59 1,129.16 1,298.53 67101 647.23 614.87 707.10 67450 1,053.94 1,001.24 1,151.43 # 67101 558.41 530.49 610.06 67500 76.38 72.56 83.44 67105 598.11 568.20 653.43 # 67500 68.88 65.44 75.26 # 67105 535.16 508.40 584.66 67505 74.74 71.00 81.65 67107 1,013.68 963.00 1,107.45 # 67505 66.87 63.53 73.06 67108 1,347.89 1,280.50 1,472.58 67515 79.47 75.50 86.83 67110 723.96 687.76 790.92 # 67515 73.10 69.45 79.87 # 67110 642.65 610.52 702.10 67550 815.71 774.92 891.16 67112 1,112.45 1,056.83 1,215.35 67560 831.12 789.56 907.99 67113 1,462.73 1,389.59 1,598.03 67570 976.51 927.68 1,066.83 67115 409.53 389.05 447.41 67700 228.20 216.79 249.31 67120 546.70 519.37 597.28 # 67700 96.29 91.48 105.20 # 67120 460.89 437.85 503.53 67710 192.73 183.09 210.55 67121 756.03 718.23 825.96 # 67710 80.69 76.66 88.16 67141 432.46 410.84 472.47 67715 202.74 192.60 221.49 # 67141 402.10 382.00 439.30 # 67715 91.06 86.51 99.49 67145 435.76 413.97 476.07 67800 106.76 101.42 116.63 # 67145 411.02 390.47 449.04 # 67800 87.65 83.27 95.76 67208 498.59 473.66 544.71 67801 136.74 129.90 149.39 # 67208 480.60 456.57 525.06 # 67801 113.51 107.83 124.00 67210 581.01 551.96 634.75 67805 169.56 161.08 185.24 # 67210 561.15 533.09 613.05 # 67805 139.58 132.60 152.49 67218 1,176.29 1,117.48 1,285.10 67808 304.16 288.95 332.29 67220 892.48 847.86 975.04 67810 195.65 185.87 213.75 # 67220 849.76 807.27 928.36 # 67810 81.36 77.29 88.88 67221 253.30 240.64 276.74 67820 44.64 42.41 48.77 # 67221 186.97 177.62 204.26 # 67820 46.13 43.82 50.39 67225 25.90 24.61 28.30 67825 108.24 102.83 118.25 # 67225 24.40 23.18 26.66 # 67825 101.50 96.43 110.89 67227 508.13 482.72 555.13 67830 227.87 216.48 248.95 # 67227 474.77 451.03 518.68 # 67830 115.83 110.04 126.55 67228 1,003.80 953.61 1,096.65 67835 369.26 350.80 403.42 # 67228 882.01 837.91 963.60 67840 237.85 225.96 259.85 67229 963.63 915.45 1,052.77 # 67840 134.05 127.35 146.45 67250 658.55 625.62 719.46 67850 191.37 181.80 209.07 67255 704.92 669.67 770.12 # 67850 120.55 114.52 131.70 67311 498.00 473.10 544.07 67875 148.41 140.99 162.14 67312 594.90 565.16 649.93 # 67875 83.21 79.05 90.91 67314 558.39 530.47 610.04 67880 382.10 363.00 417.45 67316 667.59 634.21 729.34 # 67880 304.16 288.95 332.29 67318 584.49 555.27 638.56 67882 470.69 447.16 514.23 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 NEW HAMPSHIRE - MEDICARE CARRIER 31144 PAGE 57 FSY09 LOCALITY FEE SCHEDULE FOR AREA 40 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 67882 391.63 372.05 427.86 # 68130 344.73 327.49 376.61 67900 543.66 516.48 593.95 68135 131.54 124.96 143.70 # 67900 431.61 410.03 471.53 # 68135 127.04 120.69 138.79 67901 585.70 556.42 639.88 68200 35.99 34.19 39.32 # 67901 483.39 459.22 528.10 # 68200 29.62 28.14 32.36 67902 598.20 568.29 653.53 68320 604.38 574.16 660.28 67903 518.93 492.98 566.93 # 68320 443.25 421.09 484.25 # 67903 417.75 396.86 456.39 68325 549.70 522.22 600.55 67904 614.50 583.78 671.35 68326 535.76 508.97 585.32 # 67904 496.09 471.29 541.98 68328 597.06 567.21 652.29 67906 432.73 411.09 472.75 68330 507.21 481.85 554.13 67908 414.07 393.37 452.38 # 68330 380.93 361.88 416.16 # 67908 362.35 344.23 395.86 68335 537.37 510.50 587.08 67909 455.03 432.28 497.12 68340 457.24 434.38 499.54 # 67909 370.34 351.82 404.59 # 68340 329.08 312.63 359.52 67911 464.32 441.10 507.27 68360 445.13 422.87 486.30 67912 776.47 737.65 848.30 # 68360 340.21 323.20 371.68 # 67912 418.60 397.67 457.32 68362 544.65 517.42 595.03 67914 331.85 315.26 362.55 68371 349.22 331.76 381.52 # 67914 243.79 231.60 266.34 68400 240.63 228.60 262.89 67915 297.56 282.68 325.08 # 68400 115.09 109.34 125.74 # 67915 215.50 204.73 235.44 68420 273.62 259.94 298.93 67916 456.16 433.35 498.35 # 68420 147.34 139.97 160.97 # 67916 363.97 345.77 397.64 68440 90.54 86.01 98.91 67917 497.71 472.82 543.74 # 68440 81.17 77.11 88.68 # 67917 401.78 381.69 438.94 68500 811.51 770.93 886.57 67921 316.17 300.36 345.41 68505 816.87 776.03 892.43 # 67921 228.11 216.70 249.21 68510 387.83 368.44 423.71 67922 288.20 273.79 314.86 # 68510 250.68 238.15 273.87 # 67922 207.63 197.25 226.84 68520 575.31 546.54 628.52 67923 480.42 456.40 524.86 68525 230.16 218.65 251.45 # 67923 392.36 372.74 428.65 68530 371.44 352.87 405.80 67924 497.80 472.91 543.85 # 68530 221.93 210.83 242.45 # 67924 379.01 360.06 414.07 68540 776.20 737.39 848.00 67930 312.85 297.21 341.79 68550 952.49 904.87 1,040.60 # 67930 207.92 197.52 227.15 68700 501.18 476.12 547.54 67935 506.57 481.24 553.43 68705 202.22 192.11 220.93 # 67935 380.28 361.27 415.46 # 68705 139.64 132.66 152.56 67938 208.20 197.79 227.46 68720 635.87 604.08 694.69 # 67938 96.91 92.06 105.87 68745 638.06 606.16 697.08 67950 489.75 465.26 535.05 68750 656.93 624.08 717.69 # 67950 394.57 374.84 431.07 68760 171.41 162.84 187.27 67961 489.43 464.96 534.70 # 68760 122.32 116.20 133.63 # 67961 385.63 366.35 421.30 68761 124.59 118.36 136.11 67966 643.16 611.00 702.65 # 68761 99.49 94.52 108.70 # 67966 545.73 518.44 596.21 68770 494.35 469.63 540.07 67971 615.50 584.73 672.44 68801 103.66 98.48 113.25 67973 796.57 756.74 870.25 # 68801 89.42 84.95 97.69 67974 793.24 753.58 866.62 68810 200.33 190.31 218.86 67975 581.46 552.39 635.25 # 68810 159.49 151.52 174.25 68020 100.22 95.21 109.49 68811 172.68 164.05 188.66 # 68020 93.10 88.45 101.72 68815 378.63 359.70 413.66 68040 55.68 52.90 60.84 # 68815 217.12 206.26 237.20 # 68040 45.94 43.64 50.19 68816 585.28 556.02 639.42 68100 147.29