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FEECOVPROC.v2.0

VIEWS: 140 PAGES: 435

  • pg 1
									                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      00104    7                      ANESTH. ELECTROCONVULSIVE THERAPY                                     N     3
                      00120    7                      ANESTHESIA FOR PROCEDURES ON EXTERNAL,MIDDLE,AND INNER EAR INC.BI     N     3
                      00124    7                      ANESTH. OTOSCOPY                                                      N     3
                      00126    7                      ANESTH. TYMPANOTOMY                                                   N     3
                      00140    7                      ANESTHESIA FOR PROCEDURES ON EYE;NOT OTHERWISE SPECIFIED              N     3
                      00142    7                      ANESTH. LENS SURGERY                                                  N     3
                      00144    7                      ANESTHESIA FOR PROCEDURES ON EYE                                      N     3
                      00145    7                      ANESTHESIA FOR PROCEDURES ON EYE;VITREORETINAL SURGERY                N     3
                      00147    7                      IRIDECTOMY - ANESTHESIA                                               N     3
                      00148    7                      ANESTH. OPHTHALMOSCOPY                                                N     3
                      00160    7                      ANESTHESIA FOR PROCEDURES ON NOSE AND ACCESSORY SINUSES;NOC           N     3
                      00162    7                      ANESTH. RADICAL SURGERY-NOSE                                          N     3
                      00164    7                      ANESTH. BIOPSY SOFT TISSUE-NOSE                                       N     3
                      00170    7                      ANESTH. INTRAORAL NOC                                                 N     3
                      00172    7                      ANESTH. REPAIR OF CLEFT PALATE                                        N     3
                      00174    7                      ANESTH. EXISION OF RETROPHARYNGEAL TUMOR                              N     3
                      00176    7                      ANESTH. RADICAL SURGERY-INTRAORAL                                     N     3
                      00190    7                      ANESTH. PROCS. ON FACIAL BONES OR SKULL;NOC                           N     3
                      00192    7                      ANESTH. RADICAL SURGERY-FACIAL BONES                                  N     3
                      00210    7                      ANESTHESIA FOR INTRACRANIAL PROCEDURES;NOT OTHERWISE SPECIFIED        N     3
                      00212    7                      ANESTH. SUBDURAL TAPS-INTERCRANIAL                                    N     3
                      00214    7                      ANESTH. BURR HOLES-INTERCRANIAL                                       N     3
                      00215    7                      ELEVATION OF DEPRESSED SKULL FRACTURE, EXTRADURAL(SIMPLE OR COMP.     N     3
                      00216    7                      ANESTH. VASCULAR PROCS-INTERCRANIAL                                   N     3
                      00218    7                      ANESTH. INTERCRANIAL PROCS. IN SITTING POSITION                       N     3
                      00220    7                      SPINAL FLUID SHUNTING PROCEDURES                                      N     3
                      00222    7                      ANESTH. ELECTROCOAGULATION OF INTRACRANIAL NERVE                      N     3
                      00300    7                      ANESTH. INTEGUMENTARY SYST.-NECK, ALL PROCS.                          N     3
                      00320    7                      ANESTH. ALL PROCS.ESOPHAGUS,THYR,LARY,TRACH,LYMPH 1YR OLDER           N     3
                      00322    7                      ANESTH. NEEDLE BIOPSY-THYROID                                         N     3
                      00326    7                      ANESTH. FOR ALL PROCS ON LARYNX AND TRACH IN CHILD LESS 1YR           N     3
                      00350    7                      ANESTH. PROCS. ON MAJOR VESSELS-NECK NOC                              N     3
                      00352    7                      ANESTH. SIMPLE LIGATION-NECK VESSEL                                   N     3
                      00400    7                      ANESTH. INTEG. SYST. ANTERIOR CHEST NOC                               N     3
                      00402    7                      ANESTH. RECONSTRUCTIVE PROCS. BREAST                                  N     3
                      00404    7                      ANESTH. RADICAL, MODIFIED PROCS. BREAST                               N     3
                      00406    7                      ANESTH. RADICAL,MODIFIED PROCS. BREAST W NODE DIS.                    N     3
                      00410    7                      ELECTRICAL CONVERSION OF ARRHYTHMIAS                                  N     3
                      00450    7                      ANESTH. PROCS. ON CLAVICLE-SCAPULA NOC                                N     3
                      00452    7                      ANESTH. RADICAL SURGERY-CLAVICLE-SCAPULA                              N     3
                      00454    7                      ANESTH. BIOPSY OF CLAVICLE                                            N     3
                      00470    7                      ANESTHESIA FOR PARTIAL RIB RESECTION;NOT OTHERWISE SPECIFIED          N     3
                      00472    7                      ANESTH. THORACOPLASTY (ANY TYPE)                                      N     3
                      00474    7                      ANESTH. RADICAL PROCS. RIBS                                           N     3
                      00500    7                      ANESTH. ESOPHAGUS-ALL PROCS.                                          N     3
                      00520    7                      ANESTH CLOSED CHST PROC (INC ESOPHAG,BROCHO,DIAG THORACOSCOPY)        N     3
                      00522    7                      ANESTH. NEEDLE BIOPSY-PLEURA                                          N     3




Updated: 09/22/2006                                                                                                                    Page: 1 of 435
                           NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                  PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                  00524    7                      ANESTH. PNEUMOCENTESIS                                                N     3
                  00528    7                      ANESTH. MEDIASTINOSCOPY AND DIAGNOSTIC THORACOSCOPY                   N     3
                  00529    7                      MEDIASTINOSCOPY AND DIAGNOSTIC THORACOSCOPY NOT UTILIZING ONE LUN     N     3
                  00530    7                      ANESTHESIA FOR PERMANENT TRANSVENOUS PACEMAKER INSERTION              N     3
                  00532    7                      ANESTHESIA FOR ACCESS TO CENTRAL VENOUS CIRCULATION                   N     3
                  00534    7                      ANESTHESIA FOR TRANSVENOUS INSERTION OR REPLACEMENT OF PACING         N     3
                  00537    7                      ANESTHESIA FOR CARDIAC ELECTOPHSIO PROC INCLUDING RADIOFREQUENCY      N     3
                  00539    7                      ANESTH FOR TRACH. BRONC RECONSTRUCTION                                N     3
                  00540    7                      ANESTH THRCTMY PROC, LUNGS,PLEURA,DIAPHRAGM & MEDIASTINUM             N     3
                  00541    7                      ANEST THORAC , LUNGS,PLEURA, DIAPHGRAGM UTIL. ONE LUNG VENT           N     3
                  00542    7                      ANESTH. DECORTICATION-LUNG,PLEURA ETC.                                N     3
                  00546    7                      ANESTH. PULM/NARY RESECTION W THORACOPLASTY                           N     3
                  00548    7                      ANESTH. INTRATHORACIC REP. TRACHEA-BRONCHI TRAUMA                     N     3
                  00550    7                      ANESTHESIA FOR STERNAL DEBRIDEMENT                                    N     3
                  00560    7                      ANESTH. PROCS. HEART,PERICARD,GRT VESLS WO PUMP OX                    N     3
                  00561    7                      ANES FOR PROCS ON HEART, PERICARDIL SAC AND GREAT VESSELS OF CHES     N     3
                  00562    7                      ANESTH. PROCS. HEART,PERICARD,GRT VESLS W PUMP OXY                    N     3
                  00563    7                      ANESTHESIA PROCEDURES ON HEART,PERICARDIUM,AND GREAT VESS...          N     3
                  00566    7                      ANESTHESIA FOR DIRECT CORONARY ARTERY BYPASS GRAFTING W/O P OXY       N     3
                  00580    7                      ANESTH. HEART OR HEART/LUNG TRANSPLANT                                N     3
                  00600    7                      ANESTH. PROCS. CERVICAL SPINE &CORD NOC                               N     3
                  00604    7                      ANESTH. FOR PROCEDURES ON CERVICAL SPINE AND CORD/SITTING POSITIO     N     3
                  00620    7                      ANESTH. PROCS. THORACIC SPINE & CORD NOC                              N     3
                  00622    7                      ANESTH. THORACOLUMBAR SYMPATHECTOMY                                   N     3
                  00630    7                      ANESTH. PROCS. IN LUMBAR REGION NOC                                   N     3
                  00632    7                      ANESTH. LUMBAR SYMPATHECTOMY                                          N     3
                  00634    7                      ANESTH. LUMBAR CHEMONUCLEOLYSIS                                       N     3
                  00635    7                      ANESTHESIA FOR PROCEDURES IN LUMBAR REGION;DIAG OR THERAPEUTIC        N     3
                  00640    7                      ANES FOR MAN OF SPINE OR CLOSED PROC ON CERV, THORAC, LUMBAR          N     3
                  00670    7                      ANESTH. EXTENSIVE SPINE & CORD PROCS.                                 N     3
                  00700    7                      ANESTH. PROCS. UPPER ANTERIOR ABDOMINAL WALL NOC                      N     3
                  00702    7                      ANESTH. PERCUTANEOUS LIVER BIOPSY                                     N     3
                  00730    7                      ANESTH. PROCS. UPPER POSTERIOR ABDOMINAL WALL                         N     3
                  00740    7                      ANESTH. UPPER GASTROINTESTINAL ENDOSCOPIC PROCS.                      N     3
                  00750    7                      ANESTH. HERNIA REPAIRS UPPER ABDOMEN NOC                              N     3
                  00752    7                      ANESTH. LUMBAR/VENTRAL HERNIAS-WOUND DEHISCENCE                       N     3
                  00754    7                      ANESTH. OMPHALOCELE                                                   N     3
                  00756    7                      ANESTH. TRANSABDOMINAL REPAIR-DIAPHRAGMATIC HERNIA                    N     3
                  00770    7                      ANESTH. PROCS. MAJOR ABDOMINAL BLOOD VESSELS                          N     3
                  0077T    7                      IMPLANTING AND SECURING CEREBRAL THERMAL PERFUSION PROBE              N     3
                  0078T    7                      ENDOVASCULAR REPAIR OF ABDOMINAL AORTIC ANEURYSM, PSEUDOANEURYSM      N     3
                  00790    3                      ANEST FR INTRPTNL PROCS UPP ABD INC BWL SHNT NOS                      N     3
                  00790    7                      ANESTH. INTRAPERITONEAL PROCS. UPPER ABDOMEN NOC                      N     3
                  00792    7                      ANESTH. PARTIAL HEPATECTOMY-NOT LIVER BIOPSY                          N     3
                  00794    7                      ANESTH. PANCREATECTOMY-PARTIAL OR TOTAL                               N     3
                  00796    7                      ANESTH. LIVER TRANSPLANT                                              N     3
                  00797    7                      ANESTHESIA, GATRIC RESTRICTIVE PROC FOR MORBID OBESITY                N     3




Updated: 09/22/2006                                                                                                                Page: 2 of 435
                           NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                  PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                              PA IND PAC
                  00800    7                      ANESTH. PROCS. LOWER ANTERIOR ABDOMINAL WALL NOC                     N     3
                  00802    7                      ANESTH. PANNICULECTOMY                                               N     3
                  00806    7                      ANESTH. LAPAROSCOPIC PROC.                                           N     3
                  0080T    7                      ENDOVASCULAR REPAIR OR ABDOMINAL AORTIC ANEURYSM, PSEUDOANEURYSM     N     3
                  00810    7                      ANESTH. INTESTINAL ENDOSCOPIC PROCS.                                 N     3
                  0081T    7                      PLACEMENT OF VISCERAL EXT PROSTHESIS FOR ENDORVASCULAR REPIRT OF     N     3
                  00820    7                      ANESTH.PROCS. LOWER POSTERIOR ABDOMINAL WALL                         N     3
                  00830    7                      ANESTHESIA HERNIA REPAIR LOW ABDOMEN NOC                             N     3
                  00832    7                      ANESTH. VENTRAL & INCISIONAL HERNIAS                                 N     3
                  00834    7                      ANES FOR HERNIA REPAIRS IN THE LOWER ABDOMEN UNDER 1 YR              N     3
                  00836    7                      ANES FOR HERNIA REPAIRS IN LOWER AB LESS THAN 37 WEEKS               N     3
                  00840    7                      ANESTH. INTRAPERITONEAL PROCS. LOWER ABDOMEN NOC                     N     3
                  00842    7                      ANESTH. AMNIOCENTESIS                                                N     3
                  00844    7                      ANESTH. ABDOMINOPERINEAL RESECTION                                   N     3
                  00846    7                      ANESTH. RADICAL HYSTERECTOMY                                         N     3
                  00848    7                      ANESTH. PELVIC EXENTERATION                                          N     3
                  00850    7                      ANESTH. CESAREAN SECTION                                             N     3
                  00851    7                      ANESTHESIA FOR INTRAPRAPERIONEAL PRCEDURES IN LOWER ABDOMEN          N     3
                  00855    7                      ANESTH. CESAREAN HYSTERECTOMY                                        N     3
                  00857    7                      ANESTH. CONTINUOUS LUMBAR ANALGSIA-LABOR/C'SECTION                   N     3
                  00860    7                      ANESTH. EXTRAPERIT. PROCS. LWR.ABD.-URINARY NOC                      N     3
                  00862    7                      ANESTH. RENAL PROCS. INCLU. UPR 1/3 URETER                           N     3
                  00864    7                      ANESTH. TOTAL CYSTECTOMY                                             N     3
                  00865    7                      ANESTHESIA EXTRA PERITONEAL PROC LOW ABDMN,INC URIN TRCT,F           N     3
                  00866    7                      ANESTH. ADRENALECTOMY                                                N     3
                  00868    7                      ANESTH. RENAL TRANSPLANT (RECIPIENT)                                 N     3
                  00870    7                      ANESTH. CYSTOLITOTOMY                                                N     3
                  00872    7                      ANESTH. LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE                        N     3
                  00873    7                      ANESTHESIA FOR LITHOTRIPSY, EXTRACORPOREAL SHOCK W                   N     3
                  00880    7                      ANESTH. PROCS. MAJOR LOWER ABDOMINAL VESSELS NOC                     N     3
                  00882    7                      ANESTH. INFERIOR VENA CAVA LIGATION                                  N     3
                  00902    7                      ANESTH. ANORECTAL PROC.                                              N     3
                  00904    7                      ANESTH. RADICAL PERINEAL PROC.                                       N     3
                  00906    7                      ANESTH. VULVECTOMY                                                   N     3
                  00908    7                      ANESTH. PERINEAL PROSTATECTOMY                                       N     3
                  00910    7                      ANESTH. TRANSURETHRAL PROC. NOC                                      N     3
                  00912    7                      ANESTH. TRANSURETHRAL RESECTION-BLADDER TUMORS                       N     3
                  00914    7                      ANESTH. TRANSURETHRAL RESCTION-PROSTATE                              N     3
                  00916    7                      ANESTH. POST-TRANSURETHRAL RESECTION BLEEDING                        N     3
                  00918    7                      ANESTHESIA FOR TRANSURETHRAL PROCEDURES (INCLUDING                   N     3
                  00920    7                      ANESTH. PROCS. MALE EXTERNAL GENITALIA NOC                           N     3
                  00921    7                      ANES FOR PROC ON MALE GENITALIA,VASTECTOMY UNI/BILAT                 N     3
                  00922    7                      ANESTH. SEMINAL VESICLES                                             N     3
                  00924    7                      ANESTH. UNDESCENDED TESTIS UNI/BILATERAL                             N     3
                  00926    7                      ANESTH. RADICAL ORCHIECTOMY-INGUINAL                                 N     3
                  00928    7                      ANESTH. RADICAL ORCHIECTOMY-ABDOMINAL                                N     3
                  00930    7                      ANESTH. ORCHIOPEXY UNI/BILATERAL                                     N     3




Updated: 09/22/2006                                                                                                               Page: 3 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                              PA IND PAC
                      00932    7                      ANESTH. COMPLETE AMPUTATION-PENIS                                    N     3
                      00934    7                      ANESTH. RADICAL AMPUT. PENIS W BILAT LYMPHADONCTMY                   N     3
                      00936    7                      ANESTH. RADICAL AMPUT. PENIS W BI.ING&ILIAC LYMPH.                   N     3
                      00938    7                      ANESTH. INSERTION-PENILE PROSTHESIS                                  N     3
                      00940    7                      ANESTH. VAGINAL PROCS. NOC                                           N     3
                      00942    7                      ANESTH. FOR VAGINAL PROCEDURES INCLUDING BIOPSY OF LABIA, VAGINA     N     3
                      00944    7                      ANESTH. VAGINAL HYSTERECTOMY                                         N     3
                      00948    7                      ANESTH. CERVICAL CERCLAGE                                            N     3
                      00950    7                      ANESTH. CULDOSCOPY                                                   N     3
                      00952    7                      ANESTH. HYSTEROSCOPY AND/OR HYSTEROSALPINGOGRAPHY                    N     3
                      01112    7                      ANESTHESIA FOR BONE MARROW ASPIRATION AND/OR BIOPSY ANT OR POST      N     3
                      01120    7                      ANESTHESIA FOR PROCEDURES ON BONY PELVIS                             N     3
                      01130    7                      ANESTH. BODY CAST APPLICATION/REVISION                               N     3
                      01140    7                      ANESTH. INTERPELVIABDOMINAL AMPUT. (HIND QUARTER)                    N     3
                      01150    7                      ANESTH. RADICAL PROCS. PELVIC TUMOR X HIND QTR AMP                   N     3
                      01160    7                      ANESTH. CLOSED PROCS. SYMPHYSIS PUBIS/SACRO JOINT                    N     3
                      01170    7                      ANESTH. OPEN PROCS. SYMPHYSIS PUBIS/SACRO JOINT                      N     3
                      01180    7                      ANESTH. OBTURATOR NEURECTOMY EXTRAPELVIC                             N     3
                      01190    7                      ANESTH. OBTURATOR NEURECTOMY INTRAPELVIC                             N     3
                      01200    7                      ANESTH. CLOSED PROCS. HIP JOINT                                      N     3
                      01202    7                      ANESTHESIA FOR ARTHROSCOPIC PROC OF HIP JOINT                        N     3
                      01210    7                      ANESTH. OPEN PROCS. HIP JOINT NOC                                    N     3
                      01212    7                      ANESTH. HIP DISARTICULATION                                          N     3
                      01214    7                      ANESTH. TOTAL HIP REPLACEMENT/REVISION                               N     3
                      01215    7                      ANESTHESIA FOR OPEN PROCEDURES INVOLVONG HIP JOINT;REV TOT HIP       N     3
                      01220    7                      ANESTH. ALL CLOSED PROCS. UPPER 2/3 FEMUR                            N     3
                      01230    7                      ANESTH. OPEN PROCS. UPPER 2/3 FEMUR NOC                              N     3
                      01232    7                      ANESTH. AMPUTATION UPPER 2/3 FEMUR                                   N     3
                      01234    7                      ANESTH. RADICAL RESECTION UPPER 2/3 FEMUR                            N     3
                      01250    7                      ANESTH. ALL PROCS. NERVES,MUSC,TENDS,FASCIA UP LEG                   N     3
                      01260    7                      ANESTH. ALL PROCS. VEINS UPPER LEG INC. EXPLOR.                      N     3
                      01270    7                      ANESTH. PROCS. ARTERIES UPPER LEG INCL.BYPASS NOC                    N     3
                      01272    7                      ANESTH. FEMORAL ARTERY LIGATION                                      N     3
                      01274    7                      ANESTH. FEMORAL ARTERY EMBOLECTOMY                                   N     3
                      01320    7                      ANESTH. ALL PROCS. NERVE,MUSCLE ETC. KNEE/POPLIT.                    N     3
                      01340    7                      ANESTH. ALL CLOSED PROCS. LOWER 1/3 FEMUR                            N     3
                      01360    7                      ANESTH. ALL OPEN PROCS. LOWER 1/3 FEMUR                              N     3
                      01380    7                      ANESTH. ALL CLOSED PROCS. KNEE JOINT                                 N     3
                      01382    7                      ANESTH. ARTHROSCOPIC PROCS. KNEE JOINT                               N     3
                      01390    7                      ANESTH. ALL CLOSED PROCS. UPR END TIBIA,FIB/PATELL                   N     3
                      01392    7                      ANESTH. ALL OPEN PROCS. UPR TIBIA,FIB/PATELLA                        N     3
                      01400    7                      ANESTH. OPEN PROCS. KNEE JOINT NOC                                   N     3
                      01402    7                      ANESTH. TOTAL KNEE REPLACEMENT                                       N     3
                      01404    7                      ANESTH. DISARTICULATION KNEE                                         N     3
                      01420    7                      ANESTH. ALL CAST APPLIC,REMOVE,REPAIR KNEE                           N     3
                      01430    7                      ANESTH. PROCS. VEINS KNEE/POPLITEAL AREA NOC                         N     3
                      01432    7                      ANESTH. ARTERIOVENOUS FISTULA KNEE/POPLITEAL                         N     3




Updated: 09/22/2006                                                                                                                   Page: 4 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      01440    7                      ANESTH. PROCS. ARTERIES KNEE/POPLITEAL NOC             N     3
                      01442    7                      ANESTH. POPLITEAL THROMBOENDARTERECTOMY W/WO GRAFT     N     3
                      01444    7                      ANESTH. POPLITEAL EXCISION,GRAFT/REP. OCCLUS/ANEUR     N     3
                      01462    7                      ANESTH. ALL CLOSED PROCS. LOWER LEG,ANKLE,FOOT         N     3
                      01464    7                      ANESTH. ARTHROSCOPIC PROCS. ANKLE JOINT                N     3
                      01470    7                      ANESTH. PROCS. NERVE,MUSCLE ETC. LWR LEG,ANK,FTNOC     N     3
                      01472    7                      ANESTH. REPAIR RUPTURED ACHILLES TEND. W/WO GRAFT      N     3
                      01474    7                      ANESTH. GASTROCNEMIUS RECESSION                        N     3
                      01480    7                      ANESTH. OPEN PROCS. BONES LWR LEG,ANKLE,FOOT NOC       N     3
                      01482    7                      ANESTH. RADICAL RESECTION LWR LEG,ANKLE,FOOT           N     3
                      01484    7                      ANESTH. OSTEOTOMY/OSTEOPLASTY TIBIA/FIBULA             N     3
                      01486    7                      ANESTH. TOTAL ANKLE REPLACEMENT                        N     3
                      01490    7                      ANESTH. LOWER LEG CAST APPLICATION,REMOVAL,REPAIR      N     3
                      01500    7                      ANSETH. PROCS. ARTERIES LOWER LEG INCL BYPASS NOC      N     3
                      01502    7                      ANESTH. EMBOLECTOMY LOWER LEG DIRECT/CATHETER          N     3
                      01520    7                      ANESTH. PROCS. VEINS LOWER NOC                         N     3
                      01522    7                      ANESTH. VENOUS THROMBECTOMY LOWER LEG DIRECT/CATH.     N     3
                      01610    7                      ANESTH. ALL PROCS. NERVE,MUSCLE,TEND,ETC SHLD/AXIL     N     3
                      01620    7                      ANESTH. ALL CLOSED PROCS. HUMER,STERNO/ACRCLAV/SHL     N     3
                      01622    7                      ANESTH. ARTHROSCOPIC PROCS. SHOULDER JOINT             N     3
                      01630    7                      ANESTH. OPEN PROCS. HUMER,STERN/ACROCLAV/SHLDR NOC     N     3
                      01632    7                      ANESTH. RADICAL RESECTION HUMER.CLAVICLE,SHLDR         N     3
                      01634    7                      ANESTH. SHOULDER DISARTICULATION                       N     3
                      01636    7                      ANESTH. INTERTHORACOSCAPULAR AMPUT. FOREQUARTER        N     3
                      01638    7                      ANESTH. TOTAL SHOULDER REPLACEMENT                     N     3
                      01650    7                      ANETH. PROCS. ARTERIES SHOULDER-AXILLA NOC             N     3
                      01652    7                      ANESTH. AXILLARY-BRACHIAL ANEURYSM                     N     3
                      01654    7                      ANESTH. BYPASS GRAFT SHOULDER/AXILLA                   N     3
                      01656    7                      ANESTH. AXILLARY-FEMORAL BYPASS GRAFT                  N     3
                      01670    7                      ANESTH. ALL PROCS. VEINS SHOULDER/AXILLA               N     3
                      01680    7                      ANESTH. CAST APPLICATION, REMOVE, REPAIR SHLDR NOC     N     3
                      01682    7                      ANESTH. SHOULDER SPICA                                 N     3
                      01710    7                      ANESTH. PROCS. NERVE,MUSC,TEND ETC. UPR ARM-ELBNOC     N     3
                      01712    7                      ANESTHESIA FOR PROCEDURES ON NERVES, MUSCLES, TEND     N     3
                      01714    7                      ANESTH. TENOPLASTY ELBOW TO SHOULDER                   N     3
                      01716    7                      ANESTH. TENODESIS RUPTURE LONG TENDON BICEPS           N     3
                      01730    7                      ANESTH. ALL CLOSED PROCS. HUMEROUS-ELBOW               N     3
                      01732    7                      ANESTH. ARTHROSCOPIC PROCS. ELBOW JOINT                N     3
                      01740    7                      ANESTH. OPEN PROCS. HUMERUS-ELBOW NOC                  N     3
                      01742    7                      ANESTH. OSTEOTOMY HUMERUS                              N     3
                      01744    7                      ANESTH. REPAIR NONUNION/MALUNION HUMERUS               N     3
                      01756    7                      ANESTH. RADICAL PROCS. HUMERUS-ELBOW                   N     3
                      01758    7                      ANESTH. EXCISION CYST/TUMOR HUMERUS                    N     3
                      01760    7                      ANESTH. TOTAL ELBOW REPLACEMENT                        N     3
                      01770    7                      ANESTH. PROCS. ARTERIES UPPER ARM/ELBOW NOC            N     3
                      01772    7                      ANESTH. EMBOLECTOMY UPPER ARM/ELBOW                    N     3
                      01780    7                      ANESTH. PROCS. VEINS UPPER ARM/ELBOW NOC               N     3




Updated: 09/22/2006                                                                                                     Page: 5 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                              PA IND PAC
                      01782    7                      ANESTH. PHLEBORRAPHY UPPER ARM/ELBOW                                 N     3
                      01810    7                      ANESTH. ALL PROCS. NERVE,MUSCLE ETC F'ARM,WRST,HND                   N     3
                      01820    7                      ANES CLSD PROCDS RAD ULN WRST HND BNS                                N     3
                      01829    7                      ANES DIAG ARTHROSCOPIC PROC ON WRIST                                 N     3
                      01830    7                      ANESTH. OPEN PROCS. RAD,ULNA,WRIST,HAND BONES NOC                    N     3
                      01832    7                      ANESTH. TOTAL WRIST REPLACEMENT                                      N     3
                      01840    7                      ANESTH. PROCS. ARTERIES F'ARM,WRIST,HAND NOC                         N     3
                      01842    7                      ANESTH. EMBOLECTOMY F'ARM,WRIST,HAND                                 N     3
                      01844    7                      ANESTH. VASCULAR SHUNT/SHUNT REVISION ANY TYPE                       N     3
                      01850    7                      ANESTH. PROCS. VEINS F'ARM,WRIST,HAND NOC                            N     3
                      01852    7                      ANESTH. PHLEBORRAPHY F'ARM,WRIST,HAND                                N     3
                      01860    7                      ANESTH. CAST APPLIC,REMOVE,REP-F'ARM,WRIST,HAND                      N     3
                      01905    7                      ANESTH FOR MYELOGRAPHY, DISKOGRAPHY, VERTROPLASTY                    N     3
                      01916    7                      ANESTH. ARTERIOGRAMS,NEEDLE-CAROTID/VERTEBRAL                        N     3
                      01920    7                      ANESTH. CARDIAC CATH.INCL.CORON.ARTER-VENT-OGRAPHY                   N     3
                      01922    7                      ANESTHESIA FOR COMP AX TOMO SCANNING                                 N     3
                      01924    7                      ANESTHESIA FOR THERAPEUTIC INTER RADIOLOGIC PROCEDURES               N     3
                      01925    7                      ANESTHESIA FOR THERAPEUTIC INTERVENTIONAL RADIOLOGIC PROCEDURES      N     3
                      01926    7                      ANESTHSIA FOR THERAPEUTIC INTERVENTIONAL READILOGI PROCEDURES        N     3
                      01930    7                      ANESSTHESIA FOR THERAPEUTIC INTERVENTION RADIOLOGIC PROCEDURES       N     3
                      01931    7                      ANESTHESIA FOR THERAPEUTIC INTERVENTIONAL RADIOLOGIC PROCEDURES      N     3
                      01932    7                      ANESTHESIA FOR THERAPEUTIC INTERVENTIONL RADIOLOGIC PROCEDURES       N     3
                      01933    7                      ANESTHESIA FOR THERAPEUATIC INTERVENTIONAL READOLOGIC PROCEDURES     N     3
                      01951    7                      ANESTHESIA FOR SECOND AND THIRD DEGREE BURN EXCIS OR DEBRIDEME       N     3
                      01952    7                      ANESTHESIA FOR SECOND AND THIRD DEGREE BURN EXCIS.OR DEBRIDEM.       N     3
                      01953    2                      ANESTHESIA FOR SECOND AND THIRD DEGREE BURRN EXCIS.OR DEBRIDEM       N     3
                      01958    7                      ANESTHESIA FOR EXTERNAL CEPHALIC,VERSION PROCEDURE                   N     3
                      01960    7                      ANESTHESIA FOR VAGINAL DELIVERY ONLY                                 N     3
                      01961    7                      ANESTHESIA FOR, CESAREAN DELIVERY ONLY                               N     3
                      01962    7                      ANESTHESIA FOR URGENT HYSTERECTOMY FOLLOWING DELIVERY                N     3
                      01963    7                      ANESTHESIA FOR CESAREAN HYSTERECTOMY W/O LABOR ANALG/ANESTH CARE     N     3
                      01965    7                      ANESTHESIA FOR INCOMPLETE OR MISSED ABORTION PROC.                   N     3
                      01966    7                      ANESTHESIA FOR INDUCED ABORTION PROC.                                N     3
                      01967    7                      NEURAXIAL LABOR ANALGESIA/ANESTH FOR PLNND DELIVERY                  N     3
                      01968    7                      CESAREAN DELIVERY FOLLOWING NEURAXIAL LABOR ANALGESIA/ANESTH         N     3
                      01969    7                      CESAREAN HYSTERECTOMY FOLLOWING NEURAXIAL LABOR ANALGESIA/ANESTH     N     3
                      01990    7                      ANESTH. PHYSIO. SUPPORT ORGAN HARVEST-BRAIN DEAD                     N     3
                      01991    7                      ANEST DIAG/THER NERVE BLOCKS/INJ O/T PRONE POSITION                  N     3
                      01992    7                      ANES DIAG/THER NERVE BLOCKS /INJ PRONE POSITION                      N     3
                      01995    7                      ANESTH. REG. IV ADMIN. LOCAL AGENT UPPER/LOWER EXT                   N     3
                      01996    1                      DAILY MNGMNT OF EPIDURAL OR SUBARACHNOID DRUG ADMINISTRATION         N     3
                      01996    7                      DAILY MANAGEMENT OF EPIDURAL OR SUBARACHNOID DRUG                    N     3
                      01999    7                      UNLISTED ANESTH PROCEDURE(S)                                         N     3
                      10021    1                      FINE NEEDLE ASPRIATION WITHOUT IMAGING GUIDANCE                      N     3
                      10021    2                      FINE NEEDLE ASPIRATION, W/O IMAGING GUIDANCE                         N     3
                      10022    2                      FINE NEEDLE ASPIRATION; WITH IMAGING GUIDANCE                        N     3
                      10040    2                      ACNE SURGERY(COMEDONES, CYSTS PUSTULES)                              N     3




Updated: 09/22/2006                                                                                                                   Page: 6 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      10040    7                      ACNE SURGERY(COMEDONES, CYSTS PUSTULES                                N     3
                      10060    2                      I&D ABCESS(CARBUNCLE,HIDRADENITIS)SIMPLE                              N     3
                      10060    7                      I&D ABCESS(CARBUNCLE,HIDRADENITIS)SIMPLE                              N     3
                      10061    2                      INCISION AND DRAINAGE OF ABSCESS;COMPLICATED                          N     3
                      10061    7                      INCISION AND DRAINAGE OF ABSCESS;COMPLICATED                          N     3
                      10080    2                      INCISION AND DRAINAGE OF PILONIDAL CYST;SIMPLE                        N     3
                      10080    7                      INCISION AND DRAINAGE OF PILONIDAL CYST;SIMPLE                        N     3
                      10081    2                      INCISION AND DRAINAGE OF PILONIDAL CYST;COMPLICATE                    N     3
                      10081    7                      INCISION AND DRAINAGE OF PILONIDAL CYST;COMPLICATE                    N     3
                      10120    2                      INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS                    N     3
                      10120    7                      INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS                    N     3
                      10121    2                      I&D OF FOREIGN BODY COMPLICATED                                       N     3
                      10121    7                      I&D OF FOREIGN BODY COMPLICATED                                       N     3
                      10121    F                      I&D OF FOREIGN BODY COMPLICATED                                       N     3
                      10138    7                      ANESTH. ALL CLOSED PROCS. KNEE JOINT                                  N     3
                      10140    2                      INCISION AND DRAINAGE OF HEMATOMA;SIMPLE                              N     3
                      10140    7                      INCISION AND DRAINAGE OF HEMATOMA;SIMPLE                              N     3
                      10160    2                      PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, O                    N     3
                      10160    7                      PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, O                    N     3
                      10180    2                      INCISION DRAINAGE COMPLX POST OP WND INFECTION                        N     3
                      10180    7                      INCISION DRAINAGE COMPLX POST OP WND INFECTION                        N     3
                      10180    F                      INCISION DRAINAGE COMPLX POST OP WND INFECTION                        N     3
                      11000    2                      DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN                  N     3
                      11001    2                      DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN                  N     3
                      11001    7                      DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SK                    N     3
                      11004    2                      DEBRIDEMENT OF SKIN SUBCUTANEOUS TISSUE MUSCLE AND FASCIA FOR NEC     N     3
                      11004    7                      DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE, MUSCEL AND FASCIA FOR N     N     3
                      11005    2                      DEBRIDEMENT OF SKIN SUBCUTANEOUS TISSUE MUSCEL AND FASCIA FOR NEC     N     3
                      11005    7                      DEBRIDEMENT OF SKIN SUBCUTANEOUS TSSUE MUSCEL AND FASCAI FOR NEC      N     3
                      11006    2                      DEBRIDEMENT OF SKIN SUBCUTANEOUS TISSUE MUSCLE AND FASCAI FOR NEC     N     3
                      11006    7                      DEBRIDEMENT OF SKIN SUBCUTANEOUS TISSUE MUSCLE AND FASCIA FOR NEC     N     3
                      11008    2                      REMOVAL OF PROSTHETIC MATERIAL OR MESH, ABDOMINAL WALL FOR NECROT     N     3
                      11008    7                      REMOVAL OF PROS MATERIAL OR MESH, ABDOMINAL WALL FOR NECROTIZING      N     3
                      11010    2                      DEBRIDE SKIN,REMOVAL OF FOREIGN MATERIAL ASSOC.W/OPEN FRACTURE(S)     N     3
                      11010    7                      DEBRIDE SKIN ASSOC W/OPEN FRACTURES AND/OR DISLOCATION(S)             N     3
                      11010    F                      DEBRIDE SKIN,REMOVAL OF FOREIGN MATERIAL ASSOC.W/OPEN FRACTURE(S)     N     3
                      11011    2                      DEBRIDE SKIN/MUSCLE, FX                                               N     3
                      11011    7                      DEBRIDE SKIN/MUSCLE, FX                                               N     3
                      11011    F                      DEBRIDE SKIN/MUSCLE, FX                                               N     3
                      11012    2                      DEBRIDE SKIN/MUSCLE/BONE, FX                                          N     3
                      11012    7                      DEBRIDE SKIN/MUSCLE/BONE, FX                                          N     3
                      11012    F                      DEBRIDE SKIN/MUSCLE/BONE, FX                                          N     3
                      11040    2                      DEBRIDEMENT; SKIN; PARTIAL THICKNESS                                  N     3
                      11040    7                      DEBRIDEMENT; SKIN, PARTIAL THICKNESS                                  N     3
                      11041    2                      DEBRIDEMENT; SKIN FULL THICKNESS                                      N     3
                      11041    7                      DEBRIDMENT SKIN                                                       N     3
                      11042    2                      DEBRIDEMENT; SKIN AND SUBCUTANEOUS TISSUE                             N     3




Updated: 09/22/2006                                                                                                                    Page: 7 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      11042    7                      DEBRID SKIN SUCUT                                                     N     3
                      11042    F                      DEBRIDEMENT; SKIN AND SUBCUTANEOUS TISSUE                             N     3
                      11043    2                      DEBRIDEMENT; SKIN, SUBCUTANEOUS TISSUE, AND MUSCLE                    N     3
                      11043    7                      DEBRIDEMENT SKIN SUBCU AND MUSCLE                                     N     3
                      11043    F                      DEBRIDEMENT; SKIN, SUBCUTANEOUS TISSUE, AND MUSCLE                    N     3
                      11044    2                      DEBRIED SKIN SUBCU. TISSUE, MUSCLE & BONE                             N     3
                      11044    7                      DEBRIDEMENT SK SUBCU MUSCL BONE                                       N     3
                      11044    F                      DEBRIED SKIN SUBCU. TISSUE, MUSCLE & BONE                             N     3
                      11055    2                      PARING/CUTTING OF BENIGN HYPERKERATOTI C LESION(CORN/CALLUS)SINGL     N     3
                      11055    7                      PARING/CUTTING BENIGN HYPERKERATOTI C LESION(CORN/CALLUS SINGLE       N     3
                      11056    2                      PARING/CUTTING BENIGN HYPERKERATOTI C LESION(CORN/CALLUS 2-4LEASI     N     3
                      11056    7                      PARING/CUTTING BENIGN HYPERKERATOTI C LESION CORN/CALLUS 2-4          N     3
                      11057    2                      PARING/CUTTIN BENIGN HYPERKERATOTI C LESIONS CORN/CALLUS OVER 4       N     3
                      11057    7                      PARING/CUTTIN BENIGN HYPERKERATOTI C LESION(CORN/CALLUS OVER 4        N     3
                      11100    2                      BIOPSY SUBCU. SKIN /MUCOUS MEMBRANE W/SIMPLE CLOS.                    N     3
                      11100    7                      BIOPSY SUBCU. SKIN OR MUCOUS MEMBRANE W/ SIM. CLOS                    N     3
                      11101    2                      BIOP. SUBCU/MUCOUS MEMB. SIMPLE CLOS. EA. ADD. LESION                 N     3
                      11101    7                      BIOPSY SUBCU./MUCOUS MEMB. SIMPLE CLOS EA. ADD LES                    N     3
                      11200    2                      EXC. SKIN TAGS ANY AREA UPTO 15                                       N     3
                      11200    7                      EXC SKIN TAGS ANY AREA UPTO 15                                        N     3
                      11201    2                      REMOVAL OF SKIN TAGS,MULTIPLE FIBROCUTANEOUS TAGS EA.ADD.10 LESIO     N     3
                      11201    7                      EXC SKIN TAGS EA ADD. 10TAGS                                          N     3
                      11300    2                      SHAVING OF EPIDERMAL OR DERMAL LESION, SNGL .5CM                      N     3
                      11301    2                      SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESI                    N     3
                      11302    2                      SHAVING OF EPIDERMAL OR LESION 1.1 CM -2.0 CM                         N     3
                      11303    2                      SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESI                    N     3
                      11305    2                      SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESI                    N     3
                      11306    2                      SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESI                    N     3
                      11307    2                      SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESI                    N     3
                      11308    2                      SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESI                    N     3
                      11310    2                      SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESI                    N     3
                      11311    2                      SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESI                    N     3
                      11312    2                      SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESI                    N     3
                      11313    2                      SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESI                    N     3
                      11400    2                      EXC BENIGN LES. INC MARGINS XCEPT SKIN TAG < .5CM TRUNK ARMS LE       N     3
                      11400    7                      EXC BENIGN LESION UPTO .5CM TRUNK ARMS OR LEGS                        N     3
                      11401    2                      EXC BENIGN LESION INC MARGINS .5 TO 1.CM TRUNK ARMS OR LEGS           N     3
                      11401    7                      EXC BENIGN LESION INC MARGINS .5 TO 1.CM TRUNK ARMS OR LEGS.          N     3
                      11402    2                      EXC LESION BENIGN INC MARGINS 1.CM TO2.CM TRUNK ARMS OR LEGS          N     3
                      11402    7                      EXC LESION BENIGN INC MARGINS 1CM TO 2.CM TRUNK ARMS OR LEGS          N     3
                      11403    2                      EXC BENIGN LESION INC MARGINS 2.CM TO 3.CM TRUNK ARMS OF LEGS         N     3
                      11403    7                      EXC BENIGN LESION INC MARGINS 2.CM TO 3.CM TRUNK ARMS OR LEGS         N     3
                      11404    2                      EXC BENIGN LESION INC MARGINS 3.CM TO 4.CM TRUNK ARMS OR LEGS         N     3
                      11404    7                      EXC BENIGN LESION INC MARGINS 3.CM TO 4.CM TRUNK ARMS OR LEGS         N     3
                      11404    F                      EXC BENIGN LESION 3.CM TO 4.CM TRUNK ARMS OR LEGS                     N     3
                      11406    2                      EXC BENIGN LESION INC MARGINS OVER 4CM TRUNK ARMS OR LEGS             N     3
                      11406    7                      EXC BENIGN LESION INC MARGINS OVER 4CM TRUNK ARMS OR LEGS             N     3




Updated: 09/22/2006                                                                                                                    Page: 8 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      11406    F                      EXC BENIGN LESION OVER 4CM TRUNK ARMS OR LEGS                         N     3
                      11420    2                      EXC BENIGN LESION INC MARGINS UP TO .5CM SCALP NECK HAND FEET         N     3
                      11420    7                      EXC BENIGN LESION INC MARGINS UP TO .5CM SCALP NECK HANDS FEET        N     3
                      11421    2                      EXC BEN. LESION INC MARGINS .5-1CM SCALP NECK HAND FEET GENITALI      N     3
                      11421    7                      EXC BEN. LES. INC MARGINS .5-1CM SCALP NECK HANDS FEET GENITAL        N     3
                      11422    2                      EXC BEN LESION INC MARGINS 1CM-2CM SCALP NECK HAND FEET GENITA        N     3
                      11422    7                      EXC BEN. LESION INC MARGINS 1CM TO 2CM SCALP NECK HAND FEET           N     3
                      11423    2                      EXC BENIGN LES INC MARGINS .2.-3.CM SCALP NECK HAND FEET GENITA       N     3
                      11423    7                      EXC BENIGN LES. INC MARGINS 2.-3.CM SCALP NECK HAND FEET GENIT        N     3
                      11424    2                      EXC BENIGN LES INC MARGINS 3.1-4.0 CM SCALP NECK HAND FEET GENIT      N     3
                      11424    7                      EXC BENIGN LES. INC MARGINS 3.1-4.0CM SCALP NECK HAND FEET GENIT      N     3
                      11424    F                      EXC BENIGN LES. 3.-4.CM SCALP NECK HAND FEET                          N     3
                      11426    2                      EXC BEN LESION INC MARGINS 4CM/OVER SCALP NECK HAND FEET GEN.         N     3
                      11426    7                      EXC BENIGN LES. INC MARGINS OVER 4CM SCALP NECK HND FOOT GENIT        N     3
                      11426    F                      EXC BEN LESION 4CM/OVER SCALP NECK HAND FEET GEN.                     N     3
                      11440    2                      EXC BENIGN LES INC MARGINS TO .5CM FACE EAR ELIDS NOSE LIPS MUCO      N     3
                      11440    7                      EXCISION, OTHER BENIGN LESION INC MARGINS FACE,EARS,EYELIDS,N         N     3
                      11441    2                      EXCISION, OTHER BENIGN LESION INC MARGINS;FACE,EARS,EYELIDS,NO        N     3
                      11441    7                      EXCISION, OTHER BENIGN LESION INC MARGINS ;FACE,EARS,EYELIDS,NO       N     3
                      11442    2                      EXCISION, OTHER BENIGN LESION INC MARGINS;FACE,EARS,EYELIDS,NO        N     3
                      11442    7                      EXCISION, OTHER BENIGN LESION INC MARGINS;FACE,EARS,EYELIDS,NO        N     3
                      11443    2                      EXCISION, OTHER BENIGN LESION INC MARGINS ;FACE,EARS,EYELIDS,NO       N     3
                      11443    7                      EXCISION, OTHER BENIGN LESION INC MARGINS;FACE,EARS,EYELIDS,NO        N     3
                      11444    2                      EXCISION, OTHER BENIGN LESION INC MARGINS;FACE,EARS,EYELIDS,NO        N     3
                      11444    7                      EXCISION, OTHER BENIGN LESION INC MARGINS;FACE,EARS,EYELIDS,NO        N     3
                      11444    F                      EXCISION, OTHER BENIGN LESION;FACE,EARS,EYELIDS,NO                    N     3
                      11446    2                      EXE BENIGN LESION INC MARGINS OVER 4. CM FACE EYELID LIPS ECT         N     3
                      11446    7                      EXE BENIGN LESION INC MARGINS OVER 4. CM FACE EYELID LIPS ECT         N     3
                      11446    F                      EXE BENIGN LESION OVER 4. CM FACE EYELID LIPS ECT                     N     3
                      11450    2                      EXC SUBCU TISSUE-HIDRADINITIS AXILLARY PRIME CLOS                     N     3
                      11450    7                      EXC SUBCU TISSUE-HIDRADINITIS AXILLARY PRIME CLOS                     N     3
                      11450    F                      EXC SUBCU TISSUE-HIDRADINITIS AXILLARY PRIME CLOS                     N     3
                      11451    2                      EXC SUBCU TISSUE-HIDRADENITIS AXILLARY OTHER CLO                      N     3
                      11451    7                      EXC SUBCU TISSUE-HIDRADENITIS AXILLARY OTHER CLO                      N     3
                      11451    F                      EXC SUBCU TISSUE-HIDRADENITIS AXILLARY OTHER CLO                      N     3
                      11462    2                      EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENTIS, INGUINA     N     3
                      11462    7                      EXC SUBCU TISSUE-HIDRADENITIS INGUNIAL PRIME CLO                      N     3
                      11462    F                      EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENTIS, INGUINA     N     3
                      11463    7                      EXC SUBCU TISSUE-HIDRADINITIS INGUNIAL-OTHER CLOS                     N     3
                      11463    F                      EXC SUBCU TISSUE -HIDRADINITIS INGUNIAL-OTHER CLOS                    N     3
                      11470    2                      EXC SUBCU TISSUE-HIDRADENITIS PERIANAL/UMBILICAL                      N     3
                      11470    7                      EXC SUBCU TISSUE-HIDRADENITIS PERIANAL/UMBILICAL                      N     3
                      11470    F                      EXC SUBCU TISSUE-HIDRADENITIS PERIANAL/UMBILICAL                      N     3
                      11471    7                      EXC SUBCU TISSUE-HIDRADENITIS PERIANAL/UMBILICAL                      N     3
                      11471    F                      EXC SUBCU TISSUE-HIDRADENITIS PERIANAL/UMBILICAL                      N     3
                      11600    2                      EXCISION, MALIGNANT LESION INC MARGINS- TRUNK, ARMS, OR LEGS;         N     3
                      11600    7                      EXCISION, MALIGNANT LESION INC MARGINS TRUNK, ARMS, OR LEGS;          N     3




Updated: 09/22/2006                                                                                                                    Page: 9 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      11601    2                      EXCISION MALIG LESION INC MARGINS TRUNK ARMS OR LEGS DIAM.6-1CM       N     3
                      11601    7                      EXCISION, MALIGNANT LESION INC MARGINS -TRUNK, ARMS, OR LEGS;         N     3
                      11602    2                      EXCISION, MALIGNANT LESION INC MARGINS- TRUNK, ARMS, OR LEGS;         N     3
                      11602    7                      EXCISION, MALIG LESION INC MARGINS TRUNK, ARMS, OR LEGS;              N     3
                      11603    2                      EXCISION, MALIGNANT LESION INC MARGINS- TRUNK, ARMS, OR LEGS;         N     3
                      11603    7                      EXCISION, MALIGNANT LESION INC MARGINS - TRUNK, ARMS, OR LEGS;        N     3
                      11604    2                      EXCISION, MALIGNANT LESION INC MARGINS -TRUNK, ARMS, OR LEGS;         N     3
                      11604    7                      EXCISION, MALIGNANT LESION INC MARGINS - TRUNK, ARMS, OR LEGS;        N     3
                      11604    F                      EXCISION, MALIGNANT LESION, TRUNK, ARMS, OR LEGS;                     N     3
                      11606    2                      EXCISION, MALIGNANT LESION INC MARGINS - TRUNK, ARMS, OR LEGS;        N     3
                      11606    7                      EXCISION, MALIGNANT LESION INC MARGINS -TRUNK, ARMS, OR LEGS;         N     3
                      11606    F                      EXCISION, MALIGNANT LESION, TRUNK, ARMS, OR LEGS;                     N     3
                      11620    2                      EXCISION, MALIG LESION INC MARGINS- SCALP, NECK, HANDS, FEET,GENI     N     3
                      11620    7                      EXCISION, MALIG LESION INC MARGINS- SCALP, NECK, HANDS, FEET,GENI     N     3
                      11621    2                      EXCISION, MALIG LESION INC MARGINS -SCALP, NECK, HANDS, FEET,GENI     N     3
                      11621    7                      EXCISION, MALIGN LESION INC MARGINS- SCALP, NECK, HANDS, FEET,GEN     N     3
                      11622    2                      EXCISION, MALIGN LESION INC MARGINS- SCALP, NECK, HANDS, FEET,GEN     N     3
                      11622    7                      EXCISION, MALIGN LESION INC MARGINS-SCALP, NECK, HANDS, FEET,GEN      N     3
                      11623    2                      EXCISION, MALIGN LESION INC MARGINS- SCALP, NECK, HANDS, FEET,GEN     N     3
                      11623    7                      EXCISION, MALIGN LESION INC MARGINS- SCALP, NECK, HANDS, FEET,GEN     N     3
                      11624    2                      EXCISION, MALIGN LESION INC MARGINS- SCALP, NECK, HANDS, FEET,GEN     N     3
                      11624    7                      EXCISION, MALIGN LESION INC MARGINS- SCALP, NECK, HANDS, FEET,GEN     N     3
                      11624    F                      EXCISION, MALIGNANT LESION, SCALP, NECK, HANDS, FE                    N     3
                      11626    2                      EXCISION, MALIGN LESION INC MARGINS- SCALP, NECK, HANDS, FEET,GEN     N     3
                      11626    7                      EXCISION, MALIGN LESION INCMARGINS- SCALP, NECK, HANDS, FEET,GEN      N     3
                      11626    F                      EXCISION, MALIGNANT LESION, SCALP, NECK, HANDS, FE                    N     3
                      11640    2                      EXCISION, MALIGN LESION INC MARGINS- FACE, EARS, EYELIDS, NOSE,LI     N     3
                      11640    7                      EXCISION, MALIGN LESION INC MARGINS- FACE, EARS, EYELIDS, NOSE,LI     N     3
                      11641    2                      EXCISION, MALIGN LESION INC MARGINS- FACE, EARS, EYELIDS, NOSE,L      N     3
                      11641    7                      EXCISION, MALIGN LESION INC MARGINS- FACE, EARS, EYELIDS, NOSE,LI     N     3
                      11642    2                      EXCISION, MALIGN LESION INC MARGINS- FACE, EARS, EYELIDS, NOSE,LI     N     3
                      11642    7                      EXCISION, MALIGN LESION INC MARGINS- FACE, EARS, EYELIDS, NOSE,LI     N     3
                      11643    2                      EXCISION, MALIGNANT LESION, FACE, EARS, EYELIDS, N                    N     3
                      11643    7                      EXCISION, MALIGN LESION INC MARGINS- FACE, EARS, EYELIDS, NOSE,LI     N     3
                      11643    8                      EXCISION, MALIG LESION INC MARGINS- FACE, EARS, EYELIDS,NOSE,LI       N     3
                      11644    2                      EXCISION, MALIGNANT LESION, FACE, EARS, EYELIDS, N                    N     3
                      11644    7                      EXCISION, MALIGN LESION INC MARGINS- FACE, EARS, EYELIDS, NOSE,LI     N     3
                      11644    8                      EXCISION, MALIGN LESION INC MARGINS-FACE, EARS, EYELIDS, NOSE,LI      N     3
                      11644    F                      EXCISION, MALIGNANT LESION, FACE, EARS, EYELIDS, N                    N     3
                      11646    2                      EXCISION, MALIGN LESION INC MARGINS- FACE, EARS, EYELIDS, NOSE,LI     N     3
                      11646    7                      EXCISION, MALIGN LESION INC MARGINS- FACE, EARS, EYELIDS, NOSE,LI     N     3
                      11646    F                      EXCISION, MALIGNANT LESION, FACE, EARS, EYELIDS, N                    N     3
                      11700    7                      DEBRIDEMENT OF NAILS, MANUAL; FIVE OR LESS                            N     3
                      11701    7                      DEBRIDEMENT OF NAILS, MANUAL; EACH ADDITIONAL, FIV                    N     3
                      11710    2                      DEBRIDEMENT OF NAILS, ELECTRIC GRINDER; FIVE OR LE                    N     3
                      11710    3                      DEBRIDEMENT OF NAILS; ELECTRIC GRINDER; FIVE OR LS                    N     3
                      11711    2                      DEBRIDEMENT OF NAILS, ELECTRIC GRINDER; EACH ADDIT                    N     3




Updated: 09/22/2006                                                                                                                    Page: 10 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      11719    2                      TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER                           N     3
                      11719    7                      TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER                           N     3
                      11720    2                      DEBRIDMENT NAILS ONE TO FIVE ANY METHOD                               N     3
                      11721    2                      DEBRIDMENT NAILS ANY METHOD SIX OR MORE                               N     3
                      11730    2                      AVULSION OF NAIL PLATE, PART OR COMP SIMPLE                           N     3
                      11730    7                      AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPL                    N     3
                      11732    2                      AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE;EACH ADDITION     N     3
                      11732    7                      AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPL                    N     3
                      11740    2                      EVACUATION OF SUBUNGUAL HEMATOMA                                      N     3
                      11740    7                      EVACUATION OF SUBUNGUAL HEMATOMA                                      N     3
                      11750    2                      EXC OF NAIL & NAIL MATRIX PART OR COMPL                               N     3
                      11750    7                      EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPL                    N     3
                      11752    2                      WITH AMPUTATION OF TUFT OF DISTAL PHALANX                             N     3
                      11752    7                      WITH AMPUTATION OF TUFT OF DISTAL PHALANX                             N     3
                      11755    2                      BIOPSY OF NAIL UNIT, ANY METHOD (EG, PLATE, BED, M                    N     3
                      11760    2                      RECONSTRUCTION OF NAIL BED;SIMPLE                                     N     3
                      11760    7                      RECONSTRUCTION OF NAIL BED;SIMPLE                                     N     3
                      11762    2                      RECONSTRUCTION OF NAIL BED;COMPLICATED                                N     3
                      11762    7                      RECONSTRUCTION OF NAIL BED;COMPLICATED                                N     3
                      11765    2                      WDGE EXCISN OF SKIN OF NAIL FLD (INGRN TOENAIL)                       N     3
                      11765    7                      WDGE EXCISN OF SKIN OF NAIL FLD (INGRN TOENAIL)                       N     3
                      11770    2                      EXCISION OF PILONIDAL CYST OR SINUS;SIMPLE                            N     3
                      11770    7                      EXCISION OF PILONIDAL CYST OR SINUS;SIMPLE                            N     3
                      11770    F                      EXCISION OF PILONIDAL CYST OR SINUS;SIMPLE                            N     3
                      11771    2                      EXCISION OF PILONIDAL CYST OR SINUS;EXTENSIVE                         N     3
                      11771    7                      EXCISION OF PILONIDAL CYST OR SINUS;EXTENSIVE                         N     3
                      11771    F                      EXCISION OF PILONIDAL CYST OR SINUS;EXTENSIVE                         N     3
                      11772    2                      EXCISION OF PILONIDAL CYST OR SINUS;COMPLICATED                       N     3
                      11772    7                      EXCISION OF PILONIDAL CYST OR SINUS;COMPLICATED                       N     3
                      11772    F                      EXCISION OF PILONIDAL CYST OR SINUS;COMPLICATED                       N     3
                      11900    2                      INJECTION, INTRALESIONAL; UP TO AND INCLUDING SEVE                    N     3
                      11900    7                      INJECTION, INTRALESIONAL; UP TO AND INCLUDING SEVE                    N     3
                      11901    2                      INJECTION, INTRALESIONAL; MORE THAN SEVEN LESIONS                     N     3
                      11901    7                      INJECTION, INTRALESIONAL; MORE THAN SEVEN LESIONS                     N     3
                      11920    2                      TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE O                    N     3
                      11921    2                      TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE O                    N     3
                      11922    2                      TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE O                    N     3
                      11960    2                      INSRTN/TISSUE EXPNDRS, FOR OTHER THAN BREAST, INCL SUBS EXPAN         N     3
                      11960    7                      INSERTION OF TISSUE EXPANDER                                          N     3
                      11960    F                      INSERTION OF TISSUE EXPANDER                                          N     3
                      11970    2                      REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT PROS                    N     3
                      11970    7                      REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT PROS                    N     3
                      11970    F                      REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT PROS                    N     3
                      11971    2                      REMOVAL OF TISSUE EXPANDER(S) WITHOUT INSERTION OF                    N     3
                      11971    7                      REMOVAL OF TISSUE EXPANDER(S) WITHOUT INSERTION OF                    N     3
                      11971    F                      REMOVAL OF TISSUE EXPANDER(S) WITHOUT INSERTION OF                    N     3
                      11975    2                      INSERTION OR REINSERTION, IMPLANTABLE CONTRACEPTIV                    N     3




Updated: 09/22/2006                                                                                                                    Page: 11 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      11975    7                      INSERTION OR REINSERTION, IMPLANTABLE CONTRACEPTIV                    N     3
                      11976    2                      REMOVAL WITHOUT REINSERTION, IMPLANTABLE CONTRACEP                    N     3
                      11976    7                      REMOVAL WITHOUT REINSERTION, IMPLANTABLE CONTRACEP                    N     3
                      11977    2                      REMOVAL WITH REINSERTION, IMPLANTABLE CONTRACEPTIV                    N     3
                      11980    2                      SUBCUTANEOUS HORMONE PELLET IMPLANT (ESTRADIOL&/OR TESTOSTERONE)      N     3
                      11981    2                      INSERTION, NON BIODEGRADABLE DRUG DELIVERY IMPLANT                    N     3
                      11982    2                      REMOVAL NON BIODEGRADABLE DRUG DELIVERY IMPLANT                       N     3
                      11983    2                      REMOVAL WITH REINSERTION, NON BIODEGRADABLE DRUG DELIVERY IMPLANT     N     3
                      12001    2                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK                    N     3
                      12001    7                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK                    N     3
                      12002    2                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK                    N     3
                      12002    7                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK                    N     3
                      12004    2                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK                    N     3
                      12004    7                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK                    N     3
                      12005    2                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK                    N     3
                      12005    7                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK                    N     3
                      12005    F                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK                    N     3
                      12006    2                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK                    N     3
                      12006    7                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK                    N     3
                      12006    F                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK                    N     3
                      12007    2                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK                    N     3
                      12007    7                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK                    N     3
                      12007    F                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK                    N     3
                      12011    2                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS,                    N     3
                      12011    7                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS,                    N     3
                      12013    2                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS,                    N     3
                      12014    2                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS,                    N     3
                      12014    7                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS,                    N     3
                      12015    2                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS,                    N     3
                      12015    7                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS,                    N     3
                      12016    2                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS,                    N     3
                      12016    7                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS,                    N     3
                      12016    F                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS,                    N     3
                      12017    2                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS,                    N     3
                      12017    7                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS,                    N     3
                      12017    F                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS,                    N     3
                      12018    7                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS,                    N     3
                      12018    F                      SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS,                    N     3
                      12020    2                      TREATMENT OF SUPERFICIAL WOUND DEHISCENCE                             N     3
                      12020    7                      TREATMENT OF SUPERFICIAL WOUND DEHISCENCE                             N     3
                      12020    F                      TREATMENT OF SUPERFICIAL WOUND DEHISCENCE                             N     3
                      12021    2                      TREATMENT OF SUPERFICIAL WOUND DEHISCENCE                             N     3
                      12021    7                      TREATMENT OF SUPERFICIAL WOUND DEHISCENCE                             N     3
                      12021    F                      TREATMENT OF SUPERFICIAL WOUND DEHISCENCE                             N     3
                      12031    2                      LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK A                    N     3
                      12031    7                      LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK A                    N     3
                      12032    2                      LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK A                    N     3




Updated: 09/22/2006                                                                                                                    Page: 12 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      12032    7                      LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK A     N     3
                      12034    2                      LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK A     N     3
                      12034    7                      LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK A     N     3
                      12034    F                      LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK A     N     3
                      12035    2                      LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK A     N     3
                      12035    7                      LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK A     N     3
                      12035    F                      LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK A     N     3
                      12036    2                      LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK A     N     3
                      12036    7                      LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK A     N     3
                      12036    F                      LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK A     N     3
                      12037    2                      LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK A     N     3
                      12037    7                      LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK A     N     3
                      12037    F                      LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK A     N     3
                      12041    2                      LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/O     N     3
                      12041    7                      LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/O     N     3
                      12042    2                      LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/O     N     3
                      12042    7                      LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/O     N     3
                      12044    2                      LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/O     N     3
                      12044    7                      LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/O     N     3
                      12044    F                      LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/O     N     3
                      12045    2                      LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/O     N     3
                      12045    7                      LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/O     N     3
                      12045    F                      LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/O     N     3
                      12046    2                      LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/O     N     3
                      12046    7                      LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/O     N     3
                      12046    F                      LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/O     N     3
                      12047    7                      LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/O     N     3
                      12047    F                      LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/O     N     3
                      12051    2                      LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NO     N     3
                      12051    7                      LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NO     N     3
                      12052    2                      LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NO     N     3
                      12052    7                      LAYER CLOSURE FACIAL WOUND 2.5CM TO 5.0CM              N     3
                      12053    2                      LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NO     N     3
                      12053    7                      LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NO     N     3
                      12054    2                      LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NO     N     3
                      12054    7                      LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NO     N     3
                      12054    F                      LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NO     N     3
                      12055    2                      LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NO     N     3
                      12055    7                      LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NO     N     3
                      12055    F                      LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NO     N     3
                      12056    2                      LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NO     N     3
                      12056    7                      LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NO     N     3
                      12056    F                      LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NO     N     3
                      12057    7                      LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NO     N     3
                      13100    2                      COMPLEX REPAIR OF WOUND SKIN GRAFTS 1.0-2.5CM          N     3
                      13100    7                      COMPLEX REPAIR OF WOUND SKIN GRAFTS 1.0-2.5CM          N     3
                      13100    F                      COMPLEX REPAIR OF WOUND SKIN GRAFTS 1.0-2.5CM          N     3




Updated: 09/22/2006                                                                                                     Page: 13 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      13101    2                      CMPLX REPR WOUND TRUNK 2.5 TO 7.5 CM                                  N     3
                      13101    7                      COMPLEX REPAIR OF WOUND SKIN GRAFT 1.0-2.5CM                          N     3
                      13101    F                      CMPLX REPR WOUND TRUNK 2.5 TO 7.5 CM                                  N     3
                      13102    2                      REPAIR COMPLEX TRUNK EA ADD -5CM (LIST IN ADD TO PRIMARY PROC)        N     3
                      13120    2                      COMPLEX REPAIR SCALP ARMS LEGS 1.0 TO 2.5 CM                          N     3
                      13120    7                      COMPLEX REPAIR SCALP ARMS LEGS 1.0 TO 2.5CM                           N     3
                      13120    F                      COMPLEX REPAIR SCALP ARMS LEGS 1.0 TO 2.5 CM                          N     3
                      13121    2                      COMPLEX REPAIR SCALP ARMS LEGS 2.5 CM TO 7.5CM                        N     3
                      13121    7                      COMPLEX REPAIR SCALP ARMS LEGS 2.5CM TO 7.5CM                         N     3
                      13121    F                      COMPLEX REPAIR SCALP ARMS LEGS 2.5 CM TO 7.5CM                        N     3
                      13122    2                      REPAIR COMPLEX SCALP ARMS &/OR LEGS EA ADD -5CM (LIST ADD TO PROC     N     3
                      13131    2                      COMPLEX REPAIR FACE NECK HAND FEET GEN 1CM TO 2.5                     N     3
                      13131    7                      COMPLEX REPAIR FACE NECK HAND FEET GEN 1CM TO 2.5                     N     3
                      13131    F                      COMPLEX REPAIR FACE NECK HAND FEET GEN 1CM TO 2.5                     N     3
                      13132    2                      COMPLEX REPAIR FACE NECK HAND FEET GEN 2.5CM-7.5CM                    N     3
                      13132    7                      COMPLEX REPAIR FACE NECK HAND FEET GEN 2.5CM-7.5CM                    N     3
                      13132    F                      COMPLEX REPAIR FACE NECK HAND FEET GEN 2.5CM-7.5CM                    N     3
                      13133    2                      REPAIR COMPLEX FOREHEAD/CHEECKS/CHIN/MOUTH/NECK/AXILLAE/GENITALIA     N     3
                      13150    2                      COMPLEX REPAIR FACE UP TO 1.0 CM                                      N     3
                      13150    7                      COMPLEX REPAIR FACE UP TO 1.0 CM                                      N     3
                      13150    F                      COMPLEX REPAIR FACE UP TO 1.0 CM                                      N     3
                      13151    2                      REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS;                     N     3
                      13151    7                      REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS;                     N     3
                      13151    F                      REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS;                     N     3
                      13152    2                      REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS;                     N     3
                      13152    7                      REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS;                     N     3
                      13152    F                      REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS;                     N     3
                      13153    2                      REPAIR COMPLEX EYELIDS/NOSE/EARS/&OR LIPS EA ADD -5CM ADD TO PRIM     N     3
                      13160    2                      SECNDRY CLSUR;SRGCL WOUND/DEHISCE EXTNSV/CMPLICTED                    N     3
                      13160    7                      SECNDRY CLSUR;SRGCL WOUND/DEHISCE EXTNSV/CMPLICTED                    N     3
                      13160    8                      SECNDRY CLSUR;SRGCL WOUND/DEHISCE EXTNSV/CMPLICTED                    N     3
                      13160    F                      SECNDRY CLSUR;SRGCL WOUND/DEHISCE EXTNSV/CMPLICTED                    N     3
                      14000    2                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK;                     N     3
                      14000    7                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK;                     N     3
                      14000    F                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK;                     N     3
                      14001    2                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK;                     N     3
                      14001    7                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK;                     N     3
                      14001    8                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK;                     N     3
                      14001    F                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK;                     N     3
                      14020    2                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP,                     N     3
                      14020    7                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP,                     N     3
                      14020    F                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP,                     N     3
                      14021    2                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP,                     N     3
                      14021    7                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP,                     N     3
                      14021    8                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP,                     N     3
                      14021    F                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP,                     N     3
                      14040    2                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD,CHEEKS,CHIN       N     3




Updated: 09/22/2006                                                                                                                    Page: 14 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      14040    7                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEA                    N     3
                      14040    F                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD,CHEEKS,CHIN       N     3
                      14041    2                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEA                    N     3
                      14041    7                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEA                    N     3
                      14041    8                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEA                    N     3
                      14041    F                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEA                    N     3
                      14060    2                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS                    N     3
                      14060    7                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS                    N     3
                      14060    F                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS                    N     3
                      14061    2                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS                    N     3
                      14061    7                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS                    N     3
                      14061    8                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS                    N     3
                      14061    F                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS                    N     3
                      14300    2                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, MORE TH                    N     3
                      14300    7                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, MORE TH                    N     3
                      14300    F                      ADJACENT TISSUE TRANSFER OR REARRANGEMENT, MORE TH                    N     3
                      14350    2                      FILLETED FINGER OR TOE FLAP, INCLUDING PREPARATION                    N     3
                      14350    7                      FILLETED FINGER OR TOE FLAP, INCLUDING PREPARATION                    N     3
                      14350    8                      FILLETED FINGER OR TOE FLAP, INCLUDING PREPARATION                    N     3
                      14350    F                      FILLETED FINGER OR TOE FLAP, INCLUDING PREPARATION                    N     3
                      15000    2                      SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF     N     3
                      15000    7                      EXCISIONAL PREPARATION OR CREATION OF RECIPIENT SI                    N     3
                      15000    F                      SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF     N     3
                      15001    2                      SURGICAL PREPARATION OF OPEN WONDS, BURNS OR SCAR ON INFANT/CHILD     N     3
                      15040    2                      HARVEST OF SKIN FOR TISSUE CULTURED SKIN AUTOGRAFT 100 SQ CM OR L     N     3
                      15040    7                      HARVEST OF SKIN FOR TISSUE CULTURED SKIN AUTOGRAFT 100 SQ CM OR L     N     3
                      15040    8                      HARVEST OF SKIN FOR TISSUE CLUTURED SKIN AUTOGRAFT 100 SQ CM OR L     N     3
                      15050    2                      PINCH GRAFT, SINGLE OR MULTIPLE, TO COVER SMALL UL                    N     3
                      15050    7                      PINCH GRAFT, SINGLE OR MULTIPLE, TO COVER SMALL UL                    N     3
                      15050    F                      PINCH GRAFT, SINGLE OR MULTIPLE, TO COVER SMALL UL                    N     3
                      15100    2                      SPLIT GRAFT, TRUNK, SCALP, ARMS, LEGS, HANDS, AND/                    N     3
                      15100    7                      SPLIT GRAFT, TRUNK, SCALP, ARMS, LEGS, HANDS, AND/                    N     3
                      15100    8                      SPLIT GRAFT, TRUNK, SCALP, ARMS, LEGS, HANDS, AND/                    N     3
                      15100    F                      SPLIT GRAFT, TRUNK, SCALP, ARMS, LEGS, HANDS, AND/                    N     3
                      15101    2                      SPLIT GRAFT, TRUNK, SCALP, ARMS, LEGS, HANDS, AND/                    N     3
                      15101    7                      SPLIT GRAFT, TRUNK, SCALP, ARMS, LEGS, HANDS, AND/                    N     3
                      15101    F                      SPLIT GRAFT, TRUNK, SCALP, ARMS, LEGS, HANDS, AND/                    N     3
                      15110    2                      EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS, FIRST 100 SQ CM OR LESS       N     3
                      15110    7                      EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS, FIRST 100 SQ CM OR LESS       N     3
                      15111    2                      EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS, EACH ADDITIONAL 100 SQ CM     N     3
                      15111    7                      EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR OR EAC     N     3
                      15111    8                      EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR OR EAC     N     3
                      15115    2                      EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORB     N     3
                      15115    7                      EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORB     N     3
                      15115    8                      EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORB     N     3
                      15116    2                      EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORB     N     3
                      15116    7                      EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORB     N     3




Updated: 09/22/2006                                                                                                                    Page: 15 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      15116    8                      EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORB     N     3
                      15120    2                      SPLIT GRAFT, FACE, EYELIDS, MOUTH, NECK, EARS, GENITALIA,HANDSD       N     3
                      15120    7                      SPLIT GRAFT, FACE, EYELIDS, MOUTH, NECK, EARS, GEN                    N     3
                      15120    8                      SPLIT GRAFT, FACE, EYELIDS, MOUTH, NECK, EARS, GEN                    N     3
                      15120    F                      SPLIT GRAFT, FACE, EYELIDS, MOUTH, NECK, EARS, GENITALIA,HANDSD       N     3
                      15121    2                      SPLIT GRAFT, FACE, EYELIDS, MOUTH, NECK, EARS,ORBITS,GENITALIA,HA     N     3
                      15121    7                      SPLIT GRAFT, FACE, EYELIDS, MOUTH, NECK, EARS, GEN                    N     3
                      15121    F                      SPLIT GRAFT, FACE, EYELIDS, MOUTH, NECK, EARS,ORBITS,GENITALIA,HA     N     3
                      15130    2                      DERMAL AUTOGRAFT, TRUNK, ARMS, LEGS, FIRST 100 SQ CM OR LESS          N     3
                      15131    2                      DERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ CM, O     N     3
                      15131    7                      DERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ CM, O     N     3
                      15131    8                      DERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ CM, O     N     3
                      15135    2                      DERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS     N     3
                      15135    7                      DERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS     N     3
                      15135    8                      DERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS     N     3
                      15136    2                      DERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS     N     3
                      15136    7                      DERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS     N     3
                      15136    8                      DERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS     N     3
                      15150    2                      TISSUE CULTURED EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 25      N     3
                      15150    7                      TISSUE CULTURED EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 25      N     3
                      15150    8                      TISSUE CULTURED EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 25      N     3
                      15151    2                      TISSUE CULTURED EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; ADDITIONA     N     3
                      15151    7                      TISSUE CULTURED EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; ADDITIONA     N     3
                      15151    8                      TISSUE CULTURED EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; ADDITIONA     N     3
                      15152    2                      TISSUE CULTURED EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 25      N     3
                      15152    7                      TISSUE CULTURED EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 25      N     3
                      15152    8                      TISSUE CULTURED EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 25      N     3
                      15155    2                      TISSUE CULTURED EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH,     N     3
                      15155    7                      TISSUE CULTURED EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH,     N     3
                      15155    8                      TISSUE CULTURED EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH,     N     3
                      15156    2                      TISSUE CULTURED EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH,     N     3
                      15156    7                      TISSUE CULTURED EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH      N     3
                      15156    8                      TISSUE CULTURED EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH      N     3
                      15157    2                      TISSUE CULTURED EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH,     N     3
                      15157    7                      TISSUE CULTURED EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 25      N     3
                      15157    8                      TISSUE CULTURED EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 25      N     3
                      15170    2                      ACELLULAR DERMAL REPLACEMENT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM      N     3
                      15170    7                      ACELLULAR DERMAL REPLACEMENT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM      N     3
                      15170    8                      ACELLULAR DERMAL REPLACEMENT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM      N     3
                      15171    2                      ACELLULAR DERMAL REPLACEMTN, TRUNK, ARMS, LEGS; EACH ADDITIONAL 1     N     3
                      15171    7                      ACELLULAR DERMAL REPLACEMENT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM      N     3
                      15171    8                      ACELLULAR DERMAL REPLACEMENT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM      N     3
                      15175    2                      ACELLULAR DERMAL REPLACEMENT, FACE, SCALP, EYELIDS, MOUTH, NECK,      N     3
                      15175    7                      ACELLULAR DERMAL REPLACEMENT, FACE, SCALP, EYELIDS, MOUTH, NECK,      N     3
                      15175    8                      ACELLULAR DERMAL REPLACEMENT, FACE, SCALP, EYELIDS, MOUTH, NECK,      N     3
                      15176    2                      ACELLULAR DERMAL REPLACEMENT, FACE, SCALP EYELIDS, MOUTH, NECK, E     N     3
                      15176    7                      ACELLULAR DERMAL REPLACEMENT, FACE, SCALP, EYELIDS, MOUTH, NECK,      N     3




Updated: 09/22/2006                                                                                                                    Page: 16 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      15176    8                      ACELLULAR DERMAL REPLACEMENT, FACE, SCALP, EYELIDS, MOUTH, NECK,      N     3
                      15200    2                      FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSU                    N     3
                      15200    7                      FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSU                    N     3
                      15200    F                      FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSU                    N     3
                      15201    2                      FULL THICKNESS GRAFT,FREE,INCLUDING DIRECT CLOSURE DONOR SITE,TRU     N     3
                      15201    7                      FULL THICKNESS GRAFT,FREE,INCLUDING DIRECT CLOSURE                    N     3
                      15201    F                      FULL THICKNESS GRAFT,FREE,INCLUDING DIRECT CLOSURE DONOR SITE,TRU     N     3
                      15220    2                      FULL THICKNESS GRAFT,FREE,INCLUDING DIR CLOSURE OF                    N     3
                      15220    7                      FULL THICKNESS GRAFT,FREE,INCLUDING DIR CLOSURE OF                    N     3
                      15220    F                      FULL THICKNESS GRAFT,FREE,INCLUDING DIR CLOSURE OF                    N     3
                      15221    2                      FULL THICKNESS GRAFT,FREE,INCLUDING DIR CLOSURE OF DONOR SITE         N     3
                      15221    7                      FULL THICKNESS GRAFT,FREE,INCLUDING DIR CLOSURE OF                    N     3
                      15221    F                      FULL THICKNESS GRAFT,FREE,INCLUDING DIR CLOSURE OF DONOR SITE         N     3
                      15240    2                      FULL THICKNESS GRAFT,FREE,INCLUDING DIR CLOSURE OF                    N     3
                      15240    7                      FULL THICKNESS GRAFT,FREE,INCLUDING DIR CLOSURE OF                    N     3
                      15240    F                      FULL THICKNESS GRAFT,FREE,INCLUDING DIR CLOSURE OF                    N     3
                      15241    2                      FULL THICKNESS GRAFT,FREE,INCLUDING DIR CLOSURE OF DONOR SITE         N     3
                      15241    7                      FULL THICKNESS GRAFT,FREE,INCLUDING DIR CLOSURE OF                    N     3
                      15241    F                      FULL THICKNESS GRAFT,FREE,INCLUDING DIR CLOSURE OF DONOR SITE         N     3
                      15260    2                      FULL THICKNESS GRAFT, FREE, INCLUDING DIR CLOSURE                     N     3
                      15260    7                      FULL THICKNESS GRAFT, FREE, INCLUDING DIR CLOSURE                     N     3
                      15260    F                      FULL THICKNESS GRAFT, FREE, INCLUDING DIR CLOSURE                     N     3
                      15261    2                      FULL THICKNESS GRAFT,FREE,INCLUDING DIR CLOSURE OF DONOR SITE,NOS     N     3
                      15261    7                      FULL THICKNESS GRAFT,FREE,INCLUDING DIR CLOSURE OF                    N     3
                      15261    F                      FULL THICKNESS GRAFT,FREE,INCLUDING DIR CLOSURE OF DONOR SITE,NOS     N     3
                      15300    2                      ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOUSRE, TRUNK, ARMS, LEGS; FI     N     3
                      15300    7                      ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOUSRE, TRUNK, ARMS, LEGS; FI     N     3
                      15300    8                      ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOUSRE, TRUNK, ARMS, LEGS; FI     N     3
                      15301    2                      ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOSURE, TRUNK, ARMS, LEGS; FI     N     3
                      15301    7                      ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOSURE, TRUNK, ARMS, LEGS; FI     N     3
                      15301    8                      ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOSURE, TRUNK, ARMS, LEGS; FI     N     3
                      15320    2                      ALLOGRAFT SKIN FOR TEMPOARY WOUND CLOSURE, FACE, SCALP, EYELIDS,      N     3
                      15320    7                      ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOSURE, FACE, SCALP, EYELIDS,     N     3
                      15320    8                      ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOSURE, FACE, SCALP, EYELIDS,     N     3
                      15321    2                      ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOSURE, FACE, SCALP, EYELIDS,     N     3
                      15321    7                      ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOSURE, FACE, SCALP, EYELIDS,     N     3
                      15321    8                      ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOSURE, FACE, SCALP, EYELIDS,     N     3
                      15330    2                      ACELLULAR ALLOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS       N     3
                      15330    7                      ACELLULAR ALLOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS       N     3
                      15330    8                      ACELLULAR ALLOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS       N     3
                      15331    2                      ACELLULAR DERMAL ALLOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL        N     3
                      15331    7                      ACELLULAR DERMAL ALLOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 10     N     3
                      15331    8                      ACELLULAR DERMAL ALLOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 10     N     3
                      15335    2                      ACELLULAR DERMAL ALLOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EA     N     3
                      15335    7                      ACELLULAR DERMAL ALLOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EA     N     3
                      15335    8                      ACELLULAR DERMAL ALLOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EA     N     3
                      15336    2                      ACELLULAR DERMAL ALLOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EA     N     3




Updated: 09/22/2006                                                                                                                    Page: 17 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      15336    7                      ACELLULAR DERMAL ALLOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EA     N     3
                      15340    2                      TISSUE CULTURED ALLOGENIC SKIN SUBSTITUTE; FIRST 25 SQ CM OR LESS     N     3
                      15340    7                      TISSUE CULTURED ALLOGENIC SKIN SUBSTITUTE; FIRST 25 SQ CM OR LESS     N     3
                      15340    8                      TISSUE CULTURED ALLOGENIC SKIN SUBSTITUTE; FIRST 25 SQ CM OR LESS     N     3
                      15341    2                      TISSUE CULTURED ALLOGENIC SKIN SUBSTITUTE; EACH ADDITIONAL 25 SQ      N     3
                      15341    7                      TISSUE CULTURED ALLOGENIC SKIN SUBSTITUTE; EACH ADDITIONAL 25 SQ      N     3
                      15341    8                      TISSUE CULTURED ALLOGENIC SKIN SUBSTITUTE; EACH ADDITIONAL 25 SQ      N     3
                      15360    2                      TISSUE CULTURED ALLOGENEIC DERMAL SUBSTITUTE; TRUNK, ARMS, LEGS;      N     3
                      15360    7                      TISSUE CULTURED ALLOGENIC DERMAL SUBSTITUTE; TRUNK, ARMS, LEGS, F     N     3
                      15360    8                      TISSUE CULTURED ALLOGENIC DERMAL SUBSTITUTE; TRUNK, ARMS, LEGS, F     N     3
                      15361    2                      TISSUE CULTURED ALLOGENEIC DERMAL SUBSTITUTE; EACH ADDITIONAL 100     N     3
                      15361    7                      TISSUE CULTURED ALLOGENEIC DERMAL SUBSTITUTE; EACH ADDITIONAL 100     N     3
                      15361    8                      TISSUE CULTURED ALLOGENEIC DERMAL SUBSTITUTE; EACH ADDITIONAL 100     N     3
                      15365    2                      TISSUE CULTURED ALLOGENEIC DERMAL SUBSTITUTE, FACE, SCALP, EYELID     N     3
                      15365    7                      TISSUE CULTURED ALLOGENEIC DERMAL SUBSTITUTE, FACE, SCALP, EYELID     N     3
                      15365    8                      TISSUE CULTURED ALLOGENEIC DERMAL SUBSTITUTE, FACE, SCALP, EYELID     N     3
                      15366    2                      TISSUE CULTURED ALLOGENEIC DERMAL SUBSTITUTE, FACE, SCALP, EYELID     N     3
                      15366    7                      TISSUE CULTURED ALLOGENEIC DERMAL SUBSTITUTE, FACE, SCALP, EYELID     N     3
                      15366    8                      TISSUE CULTURED ALLOGENEIC DERMAL SUBSTITUTE, FACE, SCALP, EYELID     N     3
                      15400    2                      APPLICATION OF XENOGRAFT (HETEROGRAFT), SKIN 100 SQ CM OR LESS        N     3
                      15400    7                      APPLICATION OF XENOGRAFT (HETEROGRAFT), SKIN                          N     3
                      15400    F                      APPLICATION OF XENOGRAFT (HETEROGRAFT), SKIN 100 SQ CM OR LESS        N     3
                      15401    2                      APPLICATION OF XENOGRAFT SKIN 100 SQCM                                N     3
                      15401    F                      APPLICATION OF XENOGRAFT SKIN 100 SQCM                                N     3
                      15420    2                      XENOGRAFT SKIN (DERMAL), FOR TEMPORARY WOUND CLOSURE, FACE, SCALP     N     3
                      15420    7                      XENOGRAFT SKIN (DERMAL), FOR TEMPORARY WOUND CLOSURE, FACE, SCALP     N     3
                      15420    8                      XENOGRAFT SKIN (DERMAL), FOR TEMPORARY WOUND CLOSURE, FACE, SCALP     N     3
                      15421    2                      XENOGRAFT SKIN (DERMAL) FOR TEMPORARY WOUND CLOSURE, FACE, SCALP,     N     3
                      15421    7                      XENOGRAFT SKIN (DERMAL) FOR TEMPORARY WOUND CLOSURE, FACE, SCALP,     N     3
                      15421    8                      XENOGRAFT SKIN (DERMAL) FOR TEMPORARY WOUND CLOSURE, FACE, SCALP,     N     3
                      15430    2                      ACELLULAR XENOGRAFT IMPLANT; FIRST 100 SQ CM OR LESS, OR ONE PERC     N     3
                      15430    7                      ACELLULAR XENOGRAFT IMPLANT; FIRST 100 SQ CM OR LESS, OR ONE PERC     N     3
                      15430    8                      ACELLULAR XENOGRAFT IMPLANT; FIRST 100 SQ CM OR LESS, OR ONE PERC     N     3
                      15431    2                      ACELLULAR XENOGRAFT IMPLANT; EACH ADDITIONAL 100 SQ CM, OR EACH A     N     3
                      15431    7                      ACELLULAR XENOGRAFT IMPLANT; EACH ADDITIONAL 100 SQ CM, OR EACH A     N     3
                      15431    8                      ACELLULAR XENOGRAFT IMPLANT; EACH ADDITIONAL 100 SQ CM, OR EACH A     N     3
                      15570    2                      FLAPS (SKIN AND/OR DEEP TISSUES)                                      N     3
                      15570    7                      FLAPS (SKIN AND/OR DEEP TISSUES)                                      N     3
                      15570    F                      FLAPS (SKIN AND/OR DEEP TISSUES)                                      N     3
                      15572    2                      FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITH                    N     3
                      15572    7                      FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITH                    N     3
                      15572    F                      FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITH                    N     3
                      15574    7                      FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITH                    N     3
                      15574    F                      FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITH                    N     3
                      15576    2                      FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITH                    N     3
                      15576    7                      FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITH                    N     3
                      15600    2                      INTERMEDIATE ''DELAY'' OF ANY FLAP, PRIMARY ''DELA                    N     3




Updated: 09/22/2006                                                                                                                    Page: 18 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                       PA IND PAC
                      15600    7                      INTERMEDIATE ''DELAY'' OF ANY FLAP, PRIMARY ''DELA            N     3
                      15600    F                      INTERMEDIATE ''DELAY'' OF ANY FLAP, PRIMARY ''DELA            N     3
                      15610    2                      INTERMEDIATE ''DELAY'' OF ANY FLAP, PRIMARY ''DELA            N     3
                      15610    7                      INTERMEDIATE ''DELAY'' OF ANY FLAP, PRIMARY ''DELA            N     3
                      15610    F                      INTERMEDIATE ''DELAY'' OF ANY FLAP, PRIMARY ''DELA            N     3
                      15620    2                      INTERMEDIATE ''DELAY'' OF ANY FLAP, PRIMARY ''DELA            N     3
                      15620    7                      INTERMEDIATE ''DELAY'' OF ANY FLAP, PRIMARY ''DELA            N     3
                      15620    F                      INTERMEDIATE ''DELAY'' OF ANY FLAP, PRIMARY ''DELA            N     3
                      15630    2                      INTERMEDIATE ''DELAY'' OF ANY FLAP, PRIMARY ''DELA            N     3
                      15630    7                      INTERMEDIATE ''DELAY'' OF ANY FLAP, PRIMARY ''DELA            N     3
                      15630    F                      INTERMEDIATE ''DELAY'' OF ANY FLAP, PRIMARY ''DELA            N     3
                      15650    2                      TRANSFER, INTERMEDIATE, OF ANY PEDICLE FLAP (EG,AB            N     3
                      15650    7                      TRANSFER, INTERMEDIATE, OF ANY PEDICLE FLAP (EG,AB            N     3
                      15650    F                      TRANSFER, INTERMEDIATE, OF ANY PEDICLE FLAP (EG,AB            N     3
                      15732    2                      MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP                 N     3
                      15732    7                      MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP                 N     3
                      15732    8                      MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP                 N     3
                      15732    F                      MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP                 N     3
                      15734    2                      MUSCLE, MYOCUT OR FASC FLAP ; TRUNK                           N     3
                      15734    7                      MUSCLE, MYOCUT OR FASC FLAP ; TRUNK                           N     3
                      15734    8                      MUSCLE, MYOCUT OR FASC FLAP ; TRUNK                           N     3
                      15734    F                      MUSCLE, MYOCUT OR FASC FLAP ; TRUNK                           N     3
                      15736    7                      MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP                 N     3
                      15738    2                      MUSCLE MYOCUTANEOUS OF FSCCTNS FLAP LOWER EXTRMTY             N     3
                      15738    7                      MUSCLE MYOCUTANEOUS OF FSCCTNS FLAP LOWER EXTRMTY             N     3
                      15738    8                      MUSCLE MYOCUTANEOUS OF FSCCTNS FLAP LOWER EXTRMTY             N     3
                      15738    F                      MUSCLE MYOCUTANEOUS OF FSCCTNS FLAP LOWER EXTRMTY             N     3
                      15740    2                      GRAFT; ISLAND PEDICLE FLAP                                    N     3
                      15740    7                      GRAFT; ISLAND PEDICLE FLAP                                    N     3
                      15740    F                      GRAFT; ISLAND PEDICLE FLAP                                    N     3
                      15750    2                      GRAFT; NEUROVASCULAR PEDICLE FLAP                             N     3
                      15750    7                      GRAFT; NEUROVASCULAR PEDICLE FLAP                             N     3
                      15750    8                      GRAFT; NEUROVASCULAR PEDICLE FLAP                             N     3
                      15750    F                      GRAFT; NEUROVASCULAR PEDICLE FLAP                             N     3
                      15755    2                      FREE FLAP(MICROVASCULAR TRANSFER)                             N     3
                      15755    7                      FREE FLAP(MICROVASCULAR TRANSFER)                             N     3
                      15755    8                      FREE FLAP(MIRCOVASCULAR TRANSFER)                             N     3
                      15756    2                      FREE MUSCLE/MYOCUTANEOUS FLAP W MICROVASCULAR ANASTOMOSIS     N     3
                      15756    7                      FREE MUSCLE/MYOCUTANEOUS FLAP WMICROVASCULAR ANASTOMOSIS      N     3
                      15756    8                      FREE MUSCLE/MYOCUTANEOUS FLAP WMICROVASCULAR ANASTOMOSIS      N     3
                      15757    2                      FREE SKIN FLAP W/MICROVASCULAR ANASTOMOSIS                    N     3
                      15757    7                      FREE SKIN FLAP W/MICROVASCULAR ANASTOMOSIS                    N     3
                      15757    8                      FREE SKIN FLAP W/MICROVASCULAR ANASTOMOSIS                    N     3
                      15758    2                      FREE FASCIAL FLAP W/ MICROVASCULAR ANASTOMOSIS                N     3
                      15758    7                      FREE FASCIAL FLAP W/MICROVASCULAR ANASTOMOSIS                 N     3
                      15758    8                      FREE FASCIAL FLAP W/MICROVASCULAR ANASTOMOSIS                 N     3
                      15760    2                      GRAFT; COMPOSITE, INCLUDING PRIMARY CLOSURE, DONOR            Y     3




Updated: 09/22/2006                                                                                                            Page: 19 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      15760    7                      GRAFT; COMPOSITE, INCLUDING PRIMARY CLOSURE, DONOR                    Y     3
                      15760    F                      GRAFT; COMPOSITE, INCLUDING PRIMARY CLOSURE, DONOR                    N     3
                      15770    2                      GRAFT; DERMA-FAT-FASCIA                                               N     3
                      15770    7                      GRAFT; DERMA-FAT-FASCIA                                               N     3
                      15770    8                      GRAFT; DERMA-FAT-FASCIA                                               N     3
                      15770    F                      GRAFT; DERMA-FAT-FASCIA                                               N     3
                      15775    7                      PUNCH GRAFT FOR HAIR TRANSPLANT; 1 TO 15                              N     3
                      15776    7                      PUNCH GRAFT FOR HAIR TRANSPLANT; MORE THAN 15                         N     3
                      15780    2                      DERMABRASION;TOTAL FACE (EG,FOR ACNE SCARRING,FINE WRINKLING,RHYT     N     3
                      15780    7                      ABRASION OF SKIN FOR REMOVAL OF SCARS, TATTOOS, OR                    N     3
                      15781    7                      ABRASION OF SKIN FOR REMOVAL OF SCARS,TATTOOS,KERA                    N     3
                      15782    7                      REMOVAL OF SCAR REGIONAL OTHER THAN FACIAL AREA                       N     3
                      15783    7                      DERMABRASION                                                          N     3
                      15785    7                      ABRASION OF SKIN FOR REMOVAL OF SCARS, TATTOOS, AC                    N     3
                      15786    7                      ABRASION; SINGLE LESION (EG,KERATOSIS,SCAR)                           N     3
                      15787    7                      ABRASION; EACH ADDITIONAL FOUR LESIONS OR LESS                        N     3
                      15800    7                      ABRASION OF SKIN, TOTAL FACE, COMBINED WITH SUPERF                    N     3
                      15820    7                      BLEPHAROPLASTY, LOWER EYELID;                                         N     3
                      15821    7                      BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNI                    N     3
                      15822    7                      BLEPHAROPLASTY, UPPER EYELID;                                         N     3
                      15822    F                      BLEPHAROPLASTY, UPPER EYELID;                                         N     3
                      15823    2                      BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN                     Y     3
                      15823    7                      BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN                     N     3
                      15823    8                      BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN                     N     3
                      15823    F                      BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN                     N     3
                      15831    2                      EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (                    Y     3
                      15831    7                      EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (                    N     3
                      15831    8                      EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (                    N     3
                      15831    F                      EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (                    N     3
                      15839    2                      EXCISION, EXCESSIVE SKIN                                              N     3
                      15839    7                      ANESTHESIOLOGIST EXCISION EXCESS TISSUE & SKIN OTH                    N     3
                      15839    8                      ASSIST AT SURGERY EXC. EXCESSIVE SKIN & TISSUE                        N     3
                      15840    2                      GRAFT FOR FACIAL NERVE PARALSIS INC OBTAIN GRAFT                      N     3
                      15840    7                      GRAFT FOR FACIAL NERVE PARALYSIS; FREE FASCIA GRAF                    N     3
                      15840    F                      GRAFT FOR FACIAL NERVE PARALSIS INC OBTAIN GRAFT                      N     3
                      15841    2                      GRAFT FOR FACIAL NERVE PARALYSIS; FREE MUSCLE GRAF                    N     3
                      15841    7                      GRAFT FOR FACIAL NERVE PARALYSIS; FREE MUSCLE GRAF                    N     3
                      15841    F                      GRAFT FOR FACIAL NERVE PARALYSIS; FREE MUSCLE GRAF                    N     3
                      15842    7                      GRAFT FOR FACIAL NERVE PARALYSIS; FREE MUSCLE GRAF                    N     3
                      15845    2                      GRAFT FOR FACIAL NERVE PARALYSIS; REGIONAL MUSCLE                     N     3
                      15845    7                      GRAFT FOR FACIAL NERVE PARALYSIS; REGIONAL MUSCLE                     N     3
                      15845    F                      GRAFT FOR FACIAL NERVE PARALYSIS; REGIONAL MUSCLE                     N     3
                      15850    2                      REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LO                    N     3
                      15850    7                      REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LO                    N     3
                      15851    2                      REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LO                    N     3
                      15851    7                      REMOVAL OF SUTURES UNDER ANES OTHER THAN LOCAL                        N     3
                      15852    2                      DRESSING CHANGE-OTHER THAN BURNS-W/ANESTHESIA                         N     3




Updated: 09/22/2006                                                                                                                    Page: 20 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      15852    7                      DRESSING CHANGE OTHER THAN BURNS-W/ANESTHESIA                         N     3
                      15860    2                      IV INJ OF AGENT TO TEST BLOOD FLOW IN FLAP-GRAFT                      N     3
                      15875    7                      SUCTION ASSISTED LIPECTOMY, ANY SITE(S)                               N     3
                      15876    7                      SUCTION ASSISTED LIPECTOMY                                            N     3
                      15876    F                      SUCTION ASSISTED LIPECTOMY                                            N     3
                      15877    7                      SUCTION ASSISTED LIPECTOMY                                            N     3
                      15877    F                      SUCTION ASSISTED LIPECTOMY                                            N     3
                      15878    7                      SUCTION ASSISTED LIPECTOMY                                            N     3
                      15878    F                      SUCTION ASSISTED LIPECTOMY                                            N     3
                      15879    7                      SUCTION ASSISTED LIPECTOMY                                            N     3
                      15879    F                      SUCTION ASSISTED LIPECTOMY                                            N     3
                      15920    2                      EXC COCCYGEAL PRESSURE ULCER W/COCCYGECTOMY                           N     3
                      15920    7                      EXC COCCYGEAL PRESSURE ULCER W/COCCYGECTOMY                           N     3
                      15920    F                      EXC COCCYGEAL PRESSURE ULCER W/COCCYGECTOMY                           N     3
                      15922    2                      EXC COCCYGEAL ULCER W/COCCYGECTOMY SKIN FLAP CL                       N     3
                      15922    7                      EXC COCCYGEAL ULCER W/COCCYGECTOMY SKIN FLAP CL                       N     3
                      15922    F                      EXC COCCYGEAL ULCER W/COCCYGECTOMY SKIN FLAP CL                       N     3
                      15931    2                      REMOV PRESUR ULCER                                                    N     3
                      15931    7                      EXCISION, SACRAL PRESSURE ULCER, WITH PRIMARY SUTU                    N     3
                      15931    F                      REMOV PRESUR ULCER                                                    N     3
                      15932    7                      EXCISION, SACRAL DECUBITUS ULCER; WITH OSTECTOMY                      N     3
                      15933    2                      EXC SACRAL PRESSURE ULCER WITH OSTECTOMY                              N     3
                      15933    7                      EXC SACRAL PRESSURE ULCER WITH OSTECTOMY                              N     3
                      15933    F                      EXC SACRAL PRESSURE ULCER WITH OSTECTOMY                              N     3
                      15934    2                      EXCISION, SACRAL PRESSURE ULCER, WITH LOCAL OR REG                    N     3
                      15934    7                      EXCISION, SACRAL PRESSURE ULCER, WITH LOCAL OR REG                    N     3
                      15934    8                      EXCISION, SACRAL PRESSURE ULCER, WITH LOCAL OR REG                    N     3
                      15934    F                      EXCISION, SACRAL PRESSURE ULCER, WITH LOCAL OR REG                    N     3
                      15935    2                      EXC SACRAL PRESSURE ULCER WITH OSTECTOMY                              N     3
                      15935    7                      EXC SACRAL PRESSURE ULCER WITH OSTECTOMY                              N     3
                      15935    F                      EXC SACRAL PRESSURE ULCER WITH OSTECTOMY                              N     3
                      15936    2                      EXCISION, SACRAL PRESSURE ULCER,IN PREPARATION FOR MUSCLE OR MYOC     N     3
                      15936    7                      EXCISION, SACRAL PRESSURE ULCER, WITH OTHER FLAP C                    N     3
                      15936    F                      EXCISION, SACRAL PRESSURE ULCER,IN PREPARATION FOR MUSCLE OR MYOC     N     3
                      15937    2                      EXC SACRAL PRESSURE ULCER WITH OSTECTOMY                              N     3
                      15937    7                      EXC SACRAL PRESSURE ULCER WITH OSTECTOMY                              N     3
                      15937    F                      EXC SACRAL PRESSURE ULCER WITH OSTECTOMY                              N     3
                      15940    2                      EXCISION, ISCHIAL PRESSURE ULCER, WITH PRIMARY SUT                    N     3
                      15940    7                      EXCISION, ISCHIAL PRESSURE ULCER, WITH PRIMARY SUT                    N     3
                      15940    8                      EXCISION, ISCHIAL PRESSURE ULCER, WITH PRIMARY SUT                    N     3
                      15940    F                      EXCISION, ISCHIAL PRESSURE ULCER, WITH PRIMARY SUT                    N     3
                      15941    2                      EXCISION, ISCHIAL DECUBITUS ULCER; WITH OSTECTOMY                     N     3
                      15941    7                      EXCISION, ISCHIAL DECUBITUS ULCER; WITH OSTECTOMY                     N     3
                      15941    F                      EXCISION, ISCHIAL DECUBITUS ULCER; WITH OSTECTOMY                     N     3
                      15942    7                      EXCISION, ISCHIAL DECUBITUS ULCER; SKIN AND MUSCLE                    N     3
                      15943    7                      EXCISION, ISCHIAL DECUBITUS ULCER; SKIN AND MUSCLE                    N     3
                      15944    2                      EXCISION, ISCHIAL PRESSURE ULCER, WITH LOCAL OR RE                    N     3




Updated: 09/22/2006                                                                                                                    Page: 21 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      15944    7                      EXCISION, ISCHIAL PRESSURE ULCER, WITH LOCAL OR RE                    N     3
                      15944    F                      EXCISION, ISCHIAL PRESSURE ULCER, WITH LOCAL OR RE                    N     3
                      15945    2                      EXCISION, ISCHIAL PRESSURE ULCER, WITH LOCAL OR RE                    N     3
                      15945    7                      EXCISION, ISCHIAL PRESSURE ULCER, WITH LOCAL OR RE                    N     3
                      15945    F                      EXCISION, ISCHIAL PRESSURE ULCER, WITH LOCAL OR RE                    N     3
                      15946    2                      EXCIS.ISCHIAL PRESSURE ULCER WITH OSTECTOMY IN PREPARATION FOR MU     N     3
                      15946    7                      EXCIS, ISCHIAL PRESSURE ULCER,W/OSTECTOMY,W/MUSCLE                    N     3
                      15946    8                      EXCIS, ISCHIAL PRESSURE ULCER,W/OSTECTOMY,W/MUSCLE                    N     3
                      15946    F                      EXCIS.ISCHIAL PRESSURE ULCER WITH OSTECTOMY IN PREPARATION FOR MU     N     3
                      15950    2                      EXCISION, TROCHANTERIC PRESSURE ULCER, WITH PRIMAR                    N     3
                      15950    7                      EXCISION, TROCHANTERIC PRESSURE ULCER, WITH PRIMAR                    N     3
                      15950    F                      EXCISION, TROCHANTERIC PRESSURE ULCER, WITH PRIMAR                    N     3
                      15951    2                      EXC TROCHANTERIC PRESSURE ULCER W/OSTECTOMY                           N     3
                      15951    7                      EXC TROCHANTERIC PRESSURE ULCER W/OSTECTOMY                           N     3
                      15951    F                      EXC TROCHANTERIC PRESSURE ULCER W/OSTECTOMY                           N     3
                      15952    2                      EXC TROCHANTERIC PRESSURE ULCER W/SKIN FLAP CLOSE                     N     3
                      15952    7                      EXC TROCHANTERIC PRESSURE ULCER W/SKIN FLAP CLOSE                     N     3
                      15952    F                      EXC TROCHANTERIC PRESSURE ULCER W/SKIN FLAP CLOSE                     N     3
                      15953    2                      EXCISION, TROCHANTERIC PRESSURE ULCER, W/ LOCAL RO                    N     3
                      15953    7                      EXCISION, TROCHANTERIC PRESSURE ULCER, W/ LOCAL RO                    N     3
                      15953    F                      EXCISION, TROCHANTERIC PRESSURE ULCER, W/ LOCAL RO                    N     3
                      15956    2                      EXCIS, TROCHANTERIC PRESSURE ULCER, W/MUSCLE OR MYOCUTANEOUS FLAP     N     3
                      15956    7                      EXCIS, TROCHANTERIC PRESSURE ULCER, W/MUSCLE OR MY                    N     3
                      15956    F                      EXCIS, TROCHANTERIC PRESSURE ULCER, W/MUSCLE OR MYOCUTANEOUS FLAP     N     3
                      15958    2                      EXC TROCHANERIC PRESSURE ULCER W/OSTECTOMY                            N     3
                      15958    7                      EXC TROCHANERIC PRESSURE ULCER W/OSTECTOMY                            N     3
                      15958    8                      EXC TROCHANERIC PRESSURE ULCER W/OSTECTOMY                            N     3
                      15958    F                      EXC TROCHANERIC PRESSURE ULCER W/OSTECTOMY                            N     3
                      15999    7                      EXC PRESSURE ULCER NOC                                                N     3
                      16000    2                      INITIAL TREATMENT FIRST DEGREE BURN LOCAL                             N     3
                      16020    2                      DRESSINGS AND/OR DEBRIDEMENT, INITIAL OR SUBSEQUEN                    N     3
                      16025    2                      DRESSINGS AND/OR DEBRIDEMENT, INITIAL OR SUBSEQUEN                    N     3
                      16030    2                      DRESSINGS AND/OR DEBRIDEMENT, INITIAL OR SUBSEQUEN                    N     3
                      16035    2                      ESCHAROTOMY                                                           N     3
                      16035    7                      ESCHAROTOMY;INITIAL INCISION                                          N     3
                      16036    2                      ESCHAROTOMY;EACH ADD.INCISION                                         N     3
                      17000    2                      DESTRUCTION BY ANY METHOD,INCLUDING LASER,BENIGN OR PREMALIG.LESI     N     3
                      17003    2                      DESTR.ANY METH.BENIGN/PREMALIGNANT LESIONS/W/LOCAL ANES.2-14LESIO     N     3
                      17003    7                      DESTR.BENIGN/PREMALIGNANT LESIONS W/LOCAL ANESTHESIA 2-14 LESIONS     N     3
                      17004    2                      DESTRUCTION BY ANY METHOD, INCLUDING LASER, WITH OR WITHOUT SURGI     N     3
                      17004    7                      DESTR.BENIGN/PREMALIGNANT LESIONS INCLU.LOCAL ANESTHESIA;15ORMORE     N     3
                      17106    2                      DESTRUT CUTANEOUS VASCULAR PROLIF LESIONS;< 10SQCM                    N     3
                      17107    2                      DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS/LASER TEC     N     3
                      17107    7                      DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LE                    N     3
                      17108    2                      DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS/LASER         N     3
                      17108    7                      DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LE                    N     3
                      17110    2                      DESTROY ANY METHOD UP TO 15 WARTS MILIA ECT                           N     3




Updated: 09/22/2006                                                                                                                    Page: 22 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      17110    7                      DEST ANY METHD FLT WARTS OR MOLLUS CONT UP TO 15                      N     3
                      17111    2                      DESTR,ANY METHOD,FLAT WARTS,MOLLUSCUM,CONTAGIOSUM,MILA 15 OR MORE     N     3
                      17111    7                      DESTRUC.ANY METHOD FLAT WARTS,MOLLUSCUM,CONTAGIOSUM,MILIA;15ORMOR     N     3
                      17250    2                      CHEMICAL CAUTERIZATION OF A WOUND                                     N     3
                      17250    7                      CHEMICAL CAUTERIZATION OF A WOUND                                     N     3
                      17260    2                      DESTRUCTION, MALIGNANT LESIONS                                        N     3
                      17260    7                      DESTRUCTION, MALIGNANT LESIONS                                        N     3
                      17261    2                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, TRUNK,                     N     3
                      17261    7                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, TRUNK,                     N     3
                      17262    2                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, TRUNK,                     N     3
                      17262    7                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, TRUNK,                     N     3
                      17263    2                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, TRUNK,                     N     3
                      17263    7                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, TRUNK,                     N     3
                      17264    7                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, TRUNK,                     N     3
                      17266    7                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, TRUNK,                     N     3
                      17270    2                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, SCALP,                     N     3
                      17270    7                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, SCALP,                     N     3
                      17271    2                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, SCALP,                     N     3
                      17271    7                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, SCALP,                     N     3
                      17271    8                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, SCALP,                     N     3
                      17272    2                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, SCALP,                     N     3
                      17272    7                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, SCALP,                     N     3
                      17273    7                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, SCALP,                     N     3
                      17274    7                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, SCALP,                     N     3
                      17276    7                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, SCALP,                     N     3
                      17280    2                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, FACE, E                    N     3
                      17280    7                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, FACE, E                    N     3
                      17281    2                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, FACE, E                    N     3
                      17281    7                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, FACE, E                    N     3
                      17282    2                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, FACE, E                    N     3
                      17282    7                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, FACE, E                    N     3
                      17282    8                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, FACE, E                    N     3
                      17283    7                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, FACE, E                    N     3
                      17284    7                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, FACE, E                    N     3
                      17286    7                      DESTRUCTION, MALIGNANT LESION, ANY METHOD, FACE, E                    N     3
                      17300    2                      CHEMOSURGERY INCLUD REMOVE LESION & MICROSC DELINE                    N     3
                      17300    7                      CHEMOSURGERY INCLUD REMOVE LESION & MICROSC DELINE                    N     3
                      17301    2                      CHEMOSURGERY INCLUD REMOVE LESION & MICROSC DELINE                    N     3
                      17301    7                      CHEMOSURGERY INCLUD REMOVE LESION & MICROSC DELINE                    N     3
                      17302    7                      CHEMOSURGERY (MOHS TYPE TECHNIQUE), MALIGNANCIES O                    N     3
                      17304    2                      CHEMOSURG OF WOUND INC REMOV TUMOR                                    N     3
                      17304    7                      CHEMOSURG OF WOUND INC REMOVAL OF TUMOR                               N     3
                      17305    2                      CHEMSURG (MOHR'S TECH) INC. REMOV. TUMOR 2ND STAGE                    N     3
                      17305    7                      CHEMOSURG MOHS TECH INC REMOV TUMOR 2ND STAGE                         N     3
                      17306    2                      CHEMOSURG MOHS TECH INC REMOV TUMOR 3RD STAGE                         N     3
                      17306    7                      CHEMSURG MOHS TECH INC REMOV TUMOR 3RD STAGE                          N     3
                      17307    2                      CHEMOSURG MOHS TECH INC REMOV TUMOR EA ADD STAGE                      N     3




Updated: 09/22/2006                                                                                                                    Page: 23 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      17307    7                      CHEMOSURG MOHS TECH INC REMOV TUMOR EA ADD STAGE                      N     3
                      17310    2                      CHEMOSURG MOHS TECH OVER 5 SPEC RX ANY STAGE                          N     3
                      17310    7                      CHEMOSURG MOHS TECH OVER 5 SPEC RX ANY STAGE                          N     3
                      17340    2                      CRYOTHERAPY (CO2 SLUSH, LIQUID N2)                                    N     3
                      17360    2                      CHEMICAL EXFOLIATION FOR ACNE                                         N     3
                      17999    7                      UNLISTED PROCEDURE, SKIN, MUCOUS MEMBRANE AND SUBC                    N     3
                      19000    2                      PUNCTURE ASPIRATION OF CYSTS OF BREST-1ST CYST                        N     3
                      19001    2                      PUNCTURE ASPIRATION OF CYST OF BREAST;EACH ADDITIONAL CYST            N     3
                      19001    7                      PUNCTURE ASPIRATION BREST CYST-EA ADD CYST                            N     3
                      19020    2                      MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS,                    N     3
                      19020    7                      MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS,                    N     3
                      19020    F                      MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS,                    N     3
                      19030    2                      INJECTION PROCEDURE ONLY FOR MAMMARY DUCTOGRAM OR                     N     3
                      19100    2                      BIOPSY OF BREAST; NEEDLE                                              N     3
                      19100    7                      ANESTHESIA FOR BIOPSY OF BREAST PERCUTANEOUS,NEEDLE CORE              N     3
                      19100    F                      BIOPSY OF BREAST; NEEDLE                                              N     3
                      19101    2                      BIOPSY OF BREAST; INCISIONAL                                          N     3
                      19101    7                      BIOPSY OF BREAST; OPEN INCISIONAL                                     N     3
                      19101    F                      BIOPSY OF BREAST; INCISIONAL                                          N     3
                      19102    2                      BIOPSY OF BREAST;PERCUT.NEEDLE CORE,USING IMAGING GUIDANCE            N     3
                      19102    F                      BIOPSY OF BREAST;PERCUT.NEEDLE CORE,USING IMAGING GUIDANCE            N     3
                      19103    2                      BIOPSY OF BREAST;PERCUT.AUTOM.VAC.ASSISTED OR ROTAT.BIOPSY DEVI       N     3
                      19103    F                      BIOPSY OF BREAST;PERCUT.AUTOM.VAC.ASSISTED OR ROTAT.BIOPSY DEVI       N     3
                      19110    2                      NIPPLE EXPLORATION,W OR W/OUT EXCISION                                N     3
                      19110    7                      NIPPLE EXPLORATION,W OR W/O EXCISION                                  N     3
                      19110    F                      NIPPLE EXPLORATION,W OR W/OUT EXCISION                                N     3
                      19112    2                      EXCISION OF LACTIFEROUS DUCT FISTULA                                  N     3
                      19112    7                      EXCISION OF LACTIFEROUS DUCT FISTULA                                  N     3
                      19112    F                      EXCISION OF LACTIFEROUS DUCT FISTULA                                  N     3
                      19120    2                      EXCISION OF CYST, FIBROADENOMA OR OTHER BENIGN OR MALIGNANT TUMOR     N     3
                      19120    7                      EXCISION OF CYST, FIBROADENOMA OR OTHER BENIGN OR MALIGNANT TUMOR     N     3
                      19120    F                      EXCISION OF CYST, FIBROADENOMA OR OTHER BENIGN OR MALIGNANT TUMOR     N     3
                      19125    2                      EXCISION OF BREAST LESION IDENTIFIED BY PRE-OPERATATIVE PLACEMENT     N     3
                      19125    7                      EXCISION OF BREAST LESION INDENTIFIED BY PRE-OPERATIVE PLACEMENT      N     3
                      19125    F                      EXCISION OF BREAST LESION IDENTIFIED BY PRE-OPERATATIVE PLACEMENT     N     3
                      19126    2                      EXCISION OF BREAST LESION IDENTIFIED BY PRE-OPERATIVE PLACEMENT O     N     3
                      19126    7                      EXCISION OF BREAST LESION IDENTIFIED BY PRE-OPERAT                    N     3
                      19126    F                      EXCISION OF BREAST LESION IDENTIFIED BY PRE-OPERATIVE PLACEMENT O     N     3
                      19140    2                      MASTECTOMY FOR GYNECOMASTIA THROUGH CIRCUMAREOLAR                     N     3
                      19140    7                      MASTECTOMY FOR GYNECOMASTIA THROUGH CIRCUMAREOLAR                     N     3
                      19140    F                      MASTECTOMY FOR GYNECOMASTIA THROUGH CIRCUMAREOLAR                     N     3
                      19141    7                      MASTECTOMY FOR GYNECOMASTIA THROUGH CIRCUMAREOLAR                     N     3
                      19160    2                      MASTECTOMY, PARTIAL (QUADRECTOMY OR MORE);                            N     3
                      19160    7                      MASTECTOMY, PARTIAL (QUADRECTOMY OR MORE);                            N     3
                      19160    8                      MASTECTOMY, PARTIAL (QUADRECTOMY OR MORE);                            N     3
                      19160    F                      MASTECTOMY, PARTIAL (QUADRECTOMY OR MORE);                            N     3
                      19162    2                      MASTECTOMY PARTIAL W AXILLARY LYMPHADENECTOMY                         N     3




Updated: 09/22/2006                                                                                                                    Page: 24 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                              PA IND PAC
                      19162    7                      MASTECTOMY PARTIAL W AXILLARY LYMPHADENECTOMY                        N     3
                      19162    8                      MASTECTOMY PARTIAL W AXILLARY LYMPHADENECTOMY                        N     3
                      19162    F                      MASTECTOMY PARTIAL W AXILLARY LYMPHADENECTOMY                        N     3
                      19180    2                      MASTECTOMY, SIMPLE, COMPLETE                                         N     3
                      19180    7                      MASTECTOMY, SIMPLE, COMPLETE                                         N     3
                      19180    8                      MASTECTOMY, SIMPLE, COMPLETE                                         N     3
                      19180    F                      MASTECTOMY, SIMPLE, COMPLETE                                         N     3
                      19182    2                      MASTECTOMY, SUBCUTANEOUS                                             N     3
                      19182    7                      MASTECTOMY, SUBCUTANEOUS                                             N     3
                      19182    8                      MASTECTOMY, SUBCUTANEOUS                                             N     3
                      19182    F                      MASTECTOMY, SUBCUTANEOUS                                             N     3
                      19200    2                      MASTECTOMY, RADICAL, INCLUDING PECTORAL MUSCLES, A                   N     3
                      19200    7                      MASTECTOMY, RADICAL, INCLUDING PECTORAL MUSCLES, A                   N     3
                      19200    8                      MASTECTOMY, RADICAL, INCLUDING PECTORAL MUSCLES, A                   N     3
                      19220    2                      MASTECTOMY, RADICAL, INCLUDING PECTORAL MUSCLES, A                   N     3
                      19220    7                      MASTECTOMY, RADICAL, INCLUDING PECTORAL MUSCLES, A                   N     3
                      19220    8                      MASTECTOMY, RADICAL, INCLUDING PECTORAL MUSCLES, A                   N     3
                      19240    2                      MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY L                   N     3
                      19240    7                      MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY L                   N     3
                      19240    8                      MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY L                   N     3
                      19260    2                      EXCISION OF CHEST WALL TUMOR INCLUDING RIBS                          N     3
                      19260    7                      EXCISION OF CHEST WALL TUMOR INCLUDING RIBS                          N     3
                      19271    2                      EXC CHEST WALL TUMOR W/PLASTIC RECONSTRUCT                           N     3
                      19271    7                      EXC CHEST WALL TUMOR W/PLASTIC RECONSTRUCT                           N     3
                      19271    8                      EXC CHEST WALL TUMOR W/PLASTIC RECONSTRUCT                           N     3
                      19272    2                      EXC CHEST WALL TUMOR W/MEDIAL LYMPH AND RECONST                      N     3
                      19272    7                      EXC CHEST WALL TUMOR W/MEDIAL LYMPH AND RECONST                      N     3
                      19290    2                      PREOPERATIVE PLACEMENT OF NEEDLE LOCALIZATION WIRE                   N     3
                      19290    7                      INTRODUCTION                                                         N     3
                      19290    F                      PREOPERATIVE PLACEMENT OF NEEDLE LOCALIZATION WIRE                   N     3
                      19291    2                      PREOPERATIVE PLACEMENT OF NEEDLE LOCALIZATION WIRE BREAST;EACH       N     3
                      19291    7                      PREOP PLACEMENT OF NEEDLE LOCALIZATION WIRE,BREAST                   N     3
                      19291    F                      PREOPERATIVE PLACEMENT OF NEEDLE LOCALIZATION WIRE BREAST;EACH       N     3
                      19295    2                      IMAGE GUIDED PLACEMENT,METAL.CLIP,PERCUTDURING BREAST BIOPSY         N     3
                      19296    6                      PLACEMENT OF RADIOTHERAPY AFTERLOADING BALLOON CATHETER INTO THE     N     3
                      19297    6                      PLACEMENT OF RADIOTHERAPY AFTERLOADING BALLOON CATH                  N     3
                      19298    6                      PLACEMENT OF RADIOTHERAPY AFTERLOADING BRACHYTHERAPY                 N     3
                      19316    2                      MASTOPEXY                                                            N     3
                      19316    F                      MASTOPEXY                                                            N     3
                      19318    2                      REDUCTION MAMMAPLASTY                                                Y     3
                      19318    7                      REDUCTION MAMMAPLASTY                                                N     3
                      19318    8                      REDUCTION MAMMAPLASTY                                                Y     3
                      19318    F                      REDUCTION MAMMAPLASTY                                                N     3
                      19325    F                      MAMMAPLASTY, AUGMENTATION; WITH PROSTHETIC IMPLANT                   N     3
                      19328    2                      REMOVAL OF INTACT MAMMARY IMPLANT                                    Y     3
                      19328    7                      REMOVAL OF INTACT MAMMARY IMPLANT                                    Y     3
                      19328    F                      REMOVAL OF INTACT MAMMARY IMPLANT                                    N     3




Updated: 09/22/2006                                                                                                                   Page: 25 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      19330    2                      REMOVAL OF BREAST IMPLANT MATERIAL                                    N     3
                      19330    7                      REMOVAL OF BREAST IMPLANT MATERIAL                                    N     3
                      19330    8                      REMOVAL OF BREAST IMPLANT MATERIAL                                    N     3
                      19330    F                      REMOVAL OF BREAST IMPLANT MATERIAL                                    N     3
                      19331    7                      REMOVAL OF MAMMARY IMPLANT MATERIAL; BILATERAL                        N     3
                      19340    2                      MASTOPEXY/MASTECTOMY ORRECONSTRUCT W/IMPLANT                          Y     3
                      19340    7                      MASTOPEXY/MASTECTOMY OR RECONSTRUCT W/IMPLANT                         Y     3
                      19340    F                      MASTOPEXY/MASTECTOMY ORRECONSTRUCT W/IMPLANT                          N     3
                      19342    2                      DELAYED INSERT OF IMPLANT POST MASTOPEXY ECT                          Y     3
                      19342    7                      DELAYED INSERT OF IMPLANT POST MASTOPEXY ECT                          Y     3
                      19342    F                      DELAYED INSERT OF IMPLANT POST MASTOPEXY ECT                          N     3
                      19350    2                      NIPPLE/AREOLA RECONSTRUCTION                                          Y     3
                      19350    7                      NIPPLE/AREOLA RECONSTRUCTION                                          Y     3
                      19350    F                      NIPPLE/AREOLA RECONSTRUCTION                                          N     3
                      19355    7                      CORRECTION OF INVERTED NIPPLES                                        N     3
                      19355    F                      CORRECTION OF INVERTED NIPPLES                                        N     3
                      19357    2                      BREAST RECONSTRUCTION, IMMEDIATE OR DELAYED, WITH                     N     3
                      19357    7                      BREAST RECONSTRUCTION, IMMEDIATE OR DELAYED, WITH                     N     3
                      19357    F                      BREAST RECONSTRUCTION, IMMEDIATE OR DELAYED, WITH                     N     3
                      19361    2                      BREAST RECONSTRUCTION WITH LATISSIMUS DORSI FLAP,                     Y     3
                      19361    7                      BREAST RECONSTRUCTION WITH LATISSIMUS DORSI FLAP,                     N     3
                      19361    8                      BREAST RECONSTRUCTION WITH LATISSIMUS DORSI FLAP,                     Y     3
                      19364    2                      BREAST RECONSTRUCTION WITH FREE FLAP                                  Y     3
                      19364    7                      BREAST RECONSTRUCTION WITH FREE FLAP                                  Y     3
                      19364    8                      BREAST RECONSTRUCTION WITH FREE FLAP                                  Y     3
                      19366    2                      BREAST RECONSTRUCTION WITH OTHER TECHNIQUE                            Y     3
                      19366    7                      BREAST RECONSTRUCTION WITH OTHER TECHNIQUE                            Y     3
                      19366    8                      BREAST RECONSTRUCTION WITH OTHER TECHNIQUE                            Y     3
                      19366    F                      BREAST RECONSTRUCTION WITH OTHER TECHNIQUE                            N     3
                      19367    2                      BREAST RECONSTRUCTION WITH TRAM; SINGLE PEDICLE                       Y     3
                      19368    2                      BREAST RECONSTRUCTION WITH MICROVASCULAR ANASTOMOSIS                  Y     3
                      19369    2                      BREAST RECONSTRUCTION WITH TRAM - DOUBLE PEDICLE                      Y     3
                      19371    2                      PERIPROSTHETIC CAPSULOTOMY, BREAST                                    N     3
                      19371    8                      PERIPROSTHETIC CAPSULOTOMY, BREAST                                    N     3
                      19371    F                      PERIPROSTHETIC CAPSULOTOMY, BREAST                                    N     3
                      19380    2                      REVISION OF RECONSTRUCTED BREAST                                      Y     3
                      19380    7                      REVISION OF RECONSTRUCTED BREAST                                      Y     3
                      19380    8                      REVISION OF RECONSTRUCTED BREAST                                      Y     3
                      19380    F                      REVISION OF RECONSTRUCTED BREAST                                      N     3
                      19499    7                      UNLISTED PROCEDURE, BREAST                                            N     3
                      20000    2                      INCISION OF SOFT TISSUE ABSCESS, SECONDARY TO OSTEOMYELITIS;SUPER     N     3
                      20000    7                      INCISION OF SOFT TISSUE ABSCESS, SECONDARY TO OSTE                    N     3
                      20005    2                      INCISION OF SOFT TISSUE ABSCESS, SECONDARY TO OSTE                    N     3
                      20005    7                      INCISION OF SOFT TISSUE ABSCESS, SECONDARY TO OSTE                    N     3
                      20005    F                      INCISION OF SOFT TISSUE ABSCESS, SECONDARY TO OSTE                    N     3
                      20010    2                      INCISION OF SOFT TISSUE ABSCESS, SECONDARY TO OSTE                    N     3
                      20010    7                      INCISION OF SOFT TISSUE ABSCESS, SECONDARY TO OSTE                    N     3




Updated: 09/22/2006                                                                                                                    Page: 26 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      20100    8                      EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE) NECK            N     3
                      20101    2                      EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE) CHEST           N     3
                      20101    8                      EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE) CHEST           N     3
                      20102    2                      EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE)ABD/FLNK/BCK     N     3
                      20102    7                      ANESTHESIA,EXPLORATION OF PENETRATING WOUND(SEPARATE PROC)ABD/FLN     N     3
                      20102    8                      EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE)ABD/FLNK/BCK     N     3
                      20103    2                      EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE)EXTREMITY        N     3
                      20103    8                      EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE)EXTREMITY        N     3
                      20150    2                      EXCISISION EPIPHYSEAL BAR W/OR W/O AUTOGENEOUS SOFT TISSUE GRAFT      N     3
                      20150    7                      EXCISE EPIPHYSEAL BAR W/ OR W/O AUTOGENOUS SOFT TISSUE                N     3
                      20150    8                      EXCISE EPIPHYSEAR BAR, W/ OR W/O AUTOGENOUS SOFT TISSUE GRAFT         N     3
                      20200    2                      BIOPSY, MUSCLE; SUPERFICIAL                                           N     3
                      20200    7                      BIOPSY, MUSCLE; SUPERFICIAL                                           N     3
                      20200    F                      BIOPSY, MUSCLE; SUPERFICIAL                                           N     3
                      20205    2                      BIOPSY, MUSCLE; DEEP                                                  N     3
                      20205    7                      BIOPSY, MUSCLE; DEEP                                                  N     3
                      20205    F                      BIOPSY, MUSCLE; DEEP                                                  N     3
                      20206    2                      BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE                                   N     3
                      20206    7                      BIOPSY, MUSCLE                                                        N     3
                      20206    F                      BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE                                   N     3
                      20220    2                      BIOPSY, BONE, TROCAR OR NEEDLE; SUPERFICIAL                           N     3
                      20220    7                      BIOPSY, BONE, TROCAR OR NEEDLE; SUPERFICIAL                           N     3
                      20220    F                      BIOPSY, BONE, TROCAR OR NEEDLE; SUPERFICIAL                           N     3
                      20225    2                      BIOPSY, BONE, TROCAR OR NEEDLE; DEEP                                  N     3
                      20225    7                      BIOPSY, BONE, TROCAR OR NEEDLE; DEEP                                  N     3
                      20225    F                      BIOPSY, BONE, TROCAR OR NEEDLE; DEEP                                  N     3
                      20240    2                      BIOPSY, BONE EXCISIONAL;SUPERFICIAL                                   N     3
                      20240    7                      BIOPSY, EXCISIONAL; SUPERFICIAL                                       N     3
                      20240    F                      BIOPSY, BONE EXCISIONAL;SUPERFICIAL                                   N     3
                      20245    2                      BIOPSY, EXCISIONAL; DEEP                                              N     3
                      20245    7                      BIOPSY, EXCISIONAL; DEEP                                              N     3
                      20245    F                      BIOPSY, EXCISIONAL; DEEP                                              N     3
                      20250    2                      BIOPSY, VERTEBRAL BODY, OPEN; THORACIC                                N     3
                      20250    7                      BIOPSY, VERTEBRAL BODY, OPEN; THORACIC                                N     3
                      20250    F                      BIOPSY, VERTEBRAL BODY, OPEN; THORACIC                                N     3
                      20251    2                      BIOPSY, VERTEBRAL BODY, OPEN; LUMBAR OR CERVICAL                      N     3
                      20251    7                      BIOPSY, VERTEBRAL BODY, OPEN; LUMBAR OR CERVICAL                      N     3
                      20251    8                      BIOPSY, VERTEBRAL BODY, OPEN; LUMBAR OR CERVICAL                      N     3
                      20251    F                      BIOPSY, VERTEBRAL BODY, OPEN; LUMBAR OR CERVICAL                      N     3
                      20500    2                      INJECTION OF SINUS TRACT; THERAPEUTIC                                 N     3
                      20501    2                      INJECTION OF SINUS TRACT; DIAGNOSTIC                                  N     3
                      20520    2                      REMOVAL OF FOREIGN BODY IN MUSCLE; SIMPLE                             N     3
                      20520    7                      REMOVAL OF FOREIGN BODY IN MUSCLE; SIMPLE                             N     3
                      20525    2                      REMOVAL OF FOREIGN BODY IN MUSCLE; DEEP OR COMPLIC                    N     3
                      20525    7                      REMOVAL OF FOREIGN BODY IN MUSCLE; DEEP OR COMPLIC                    N     3
                      20525    F                      REMOVAL OF FOREIGN BODY IN MUSCLE; DEEP OR COMPLIC                    N     3
                      20526    1                      INJECTION, THERAPEUTIC (EG, LOCAL ANESTHETIC CORTICOSTEROID CARPA     N     3




Updated: 09/22/2006                                                                                                                    Page: 27 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      20526    2                      INJECTION,THERAPEUTIC(EG LOCAL ANESTH,CORTICOS,CARPEL TUNNEL          N     3
                      20550    2                      INJECTION, TENDON SHEATH, LIGAMENT, TRIGGER POINTS OR GANGION CYS     N     3
                      20550    3                      INJECTION,TENDON SHEATH, LIGAMEN, TRIGGER POINTS                      N     3
                      20550    7                      INJECTION, TENDON SHEATH, LIGAMENT, TRIGGER POINTS                    N     3
                      20551    1                      INJECTION, TENDON ORIGIN/INSERTION                                    N     3
                      20551    2                      INJECTN,THERAPETC,EG LOCAL ANESTH CORTESTEROID,SNGL TENDON            N     3
                      20551    7                      INJECTN,THERPETC(EG LOCL ANEST,CORTICOSTERIOD,SNGL TENDON             N     3
                      20552    2                      INJECTION SINGLE OR MULTIPLE TRIGGER POINT(S) ONE OR TWO MUSCLE       N     3
                      20552    7                      INJECTN, SNGL OR MULT TRIGGER PNTS, 1 OR 2 MUSCLES                    N     3
                      20553    2                      INJECTION: SINGLE OR MULTIPLE TRIGGER POINT THRE OR MORE MUSCLE       N     3
                      20553    7                      INJECTION,SINGLE OR MULTIPLE TRIGGER POINT 3 OR MORE MUSCLES          N     3
                      20600    2                      ARTHROCENTESIS, ASPIRATION AND/OR INJECTION; SMALL                    N     3
                      20600    7                      ARTHROCENTESIS, ASPIRATION AND/OR INJECTION; SMALL                    N     3
                      20605    2                      ARTHROCENTESIS, ASPIRATION AND/OR INJECTION; INTER                    N     3
                      20605    7                      ARTHROCENTESIS, ASPIRATION AND/OR INJECTION; INTER                    N     3
                      20610    2                      ARTHROCENTESIS, ASPIRATION AND/OR INJECTION; MAJOR                    N     3
                      20610    3                      ARTHROCENTESIS, ASPIRATION AND/OR INJECTION;MAJOR                     N     3
                      20610    7                      ARTHROCENTESIS, ASPIRATION AND/OR INJECTION; MAJOR                    N     3
                      20612    2                      ASPIRATION &/OR INJ GANGLION CYST(S) ANY LOCATION                     N     3
                      20615    2                      ASPIRATION AND INJECTION FOR TREATMENT OF BONE CYS                    N     3
                      20615    7                      ASPIRATION AND INJECTION FOR TREATMENT OF BONE CYS                    N     3
                      20650    2                      INSERTION OF WIRE OR PIN FOR SKELETAL TRACTION, IN                    N     3
                      20650    7                      INSERTION OF WIRE OR PIN FOR SKELETAL TRACTION, IN                    N     3
                      20650    F                      INSERTION OF WIRE OR PIN FOR SKELETAL TRACTION, IN                    N     3
                      20660    2                      APPLICATION OF TONGS OR CALIPER, INCLUDING REMOVAL                    N     3
                      20660    7                      APPLICATION OF TONGS OR CALIPER, INCLUDING REMOVAL                    N     3
                      20661    2                      APPLICATION OF HALO; CRANIAL                                          N     3
                      20661    7                      APPLICATION OF HALO; CRANIAL                                          N     3
                      20662    2                      APPLICATION OF HALO; PELVIC                                           N     3
                      20662    7                      APPLICATION OF HALO; PELVIC                                           N     3
                      20663    2                      APPLICATION OF HALO; FEMORAL                                          N     3
                      20663    7                      APPLICATION OF HALO; FEMORAL                                          N     3
                      20664    2                      APPLY HALO,INCL.REMOVAL,CRANIAL,6OR MORE PINS(PEDI;W/GEN.ANESTH       N     3
                      20664    7                      APPLY HALO,INC.REMOVAL,CRANIAL,6 OR MORE PINS;PEDIATRIC,W/GENANES     N     3
                      20664    8                      APPLY HALO,INC.REMOVAL,CRANIAL,6OR MORE PINS,PEDIATRIC.W/GENANEST     N     3
                      20665    2                      REMOVAL OF TONGS OR HALO APPLIED BY ANOTHER PHYSIC                    N     3
                      20665    7                      REMOVAL OF TONGS OR HALO APPLIED BY ANOTHER PHYSIC                    N     3
                      20670    2                      REMOVAL OF IMPLANT; SUPERFICIAL,(EG.BURIED WIRE, PIN OR ROD)          N     3
                      20670    7                      REMOVAL OF IMPLANT; SUPERFICIAL                                       N     3
                      20670    F                      REMOVAL OF IMPLANT; SUPERFICIAL,(EG.BURIED WIRE, PIN OR ROD)          N     3
                      20680    2                      REMOVAL OF IMPLANT; DEEP                                              N     3
                      20680    7                      REMOVAL OF IMPLANT; DEEP                                              N     3
                      20680    8                      REMOVAL OF IMPLANT; DEEP                                              N     3
                      20680    F                      REMOVAL OF IMPLANT; DEEP                                              N     3
                      20690    2                      APPLICATION OF EXTERNAL FIXATION SYSTEM (EG,HOFFMA                    N     3
                      20690    7                      APPLICATION OF EXTERNAL FIXATION SYSTEM (EG,HOFFMA                    N     3
                      20690    8                      APPLICATION OF EXTERNAL FIXATION SYS - HOFFMAN                        N     3




Updated: 09/22/2006                                                                                                                    Page: 28 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      20690    F                      APPLICATION OF EXTERNAL FIXATION SYSTEM (EG,HOFFMA     N     3
                      20692    2                      APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE     N     3
                      20692    7                      APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE     N     3
                      20692    8                      APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE     N     3
                      20692    F                      APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE     N     3
                      20693    2                      ADJUSTMENT OR REVISION OF EXTERNAL FIXATION SYSTEM     N     3
                      20693    7                      ADJUSTMENT OR REVISION OF EXTERNAL FIXATION SYSTEM     N     3
                      20693    F                      ADJUSTMENT OR REVISION OF EXTERNAL FIXATION SYSTEM     N     3
                      20694    2                      REMOVAL, UNDER ANESTHESIA, OF EXTERNAL FIXATION SY     N     3
                      20694    7                      REMOVAL, UNDER ANESTHESIA, OF EXTERNAL FIXATION SY     N     3
                      20694    8                      REMOVAL, UNDER ANESTHESIA, OF EXTERNAL FIXATION SY     N     3
                      20694    F                      REMOVAL, UNDER ANESTHESIA, OF EXTERNAL FIXATION SY     N     3
                      20750    7                      REPAIR                                                 N     3
                      20802    7                      REPLANTATION, ARM; COMPLETE                            N     3
                      20804    7                      REIMPLANTATION, ARM; INCOMPLETE                        N     3
                      20805    7                      REPLANTATION, FOREARM (INCLUDES RADIUS AND ULNA TO     N     3
                      20806    7                      REPLANTATION, FOREARM (INCLUDES RADIUS AND ULNA TO     N     3
                      20808    7                      REPLANTATION, HAND; COMPLETE                           N     3
                      20812    7                      REIMPLANTATION, HAND; INCOMPLETE                       N     3
                      20816    2                      REPLANTATION, DIGIT; COMPLETE                          N     3
                      20816    7                      REPLANTATION, DIGIT; COMPLETE                          N     3
                      20820    2                      REIMPLANTATION, DIGIT; INCOMPLETE                      N     3
                      20820    7                      REIMPLANTATION, DIGIT; INCOMPLETE                      N     3
                      20822    7                      REPLANTATION, DIGIT, EXCLUDING THUMB (INCLUDES DIS     N     3
                      20823    7                      REPLANTATION, DIGIT, EXCLUDING THUMB (INCLUDES DIS     N     3
                      20824    7                      REPLANTATION, THUMB (INCLUDES CARPOMETACARPAL JOIN     N     3
                      20826    7                      REPLANTATION, THUMB (INCLUDES CARPOMETACARPAL JOIN     N     3
                      20827    7                      REPLANTATION, THUMB (INCLUDES DISTAL TIP TO MP JOI     N     3
                      20828    7                      REPLANTATION, THUMB (INCLUDES DISTAL TIP TO MP JOI     N     3
                      20832    7                      REPLANTATION, LEG; COMPLETE                            N     3
                      20834    7                      REPLANTATION, LEG; INCOMPLETE (NONVIABLE EXTREMITY     N     3
                      20838    7                      REPLANTATION, FOOT; COMPLETE                           N     3
                      20840    7                      REPLANTATION, FOOT; INCOMPLETE (NONVIABLE EXTREMIT     N     3
                      20900    2                      BONE GRAFT, ANY DONOR AREA; MINOR OR SMALL             N     3
                      20900    7                      BONE GRAFT, ANY DONOR AREA; MINOR OR SMALL             N     3
                      20900    8                      BONE GRAFT, ANY DONOR AREA; MINOR OR SMALL             N     3
                      20900    F                      BONE GRAFT, ANY DONOR AREA; MINOR OR SMALL             N     3
                      20902    2                      BONE GRAFT, ANY DONOR AREA; MAJOR OR LARGE             N     3
                      20902    7                      BONE GRAFT, ANY DONOR AREA; MAJOR OR LARGE             N     3
                      20902    8                      BONE GRAFT, ANY DONOR AREA; MAJOR OR LARGE             N     3
                      20902    F                      BONE GRAFT, ANY DONOR AREA; MAJOR OR LARGE             N     3
                      20910    2                      CARTILAGE GRAFT; COSTOCHONDRAL                         N     3
                      20910    7                      CARTILAGE GRAFT; COSTOCHONDRAL                         N     3
                      20910    F                      CARTILAGE GRAFT; COSTOCHONDRAL                         N     3
                      20912    2                      CARTILAGE GRAFT; NASAL SEPTUM                          N     3
                      20912    7                      CARTILAGE GRAFT; NASAL SEPTUM                          N     3
                      20912    F                      CARTILAGE GRAFT; NASAL SEPTUM                          N     3




Updated: 09/22/2006                                                                                                     Page: 29 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      20920    2                      FASCIA LATA GRAFT; BY STRIPPER                                        N     3
                      20920    7                      FASCIA LATA GRAFT; BY STRIPPER                                        N     3
                      20920    F                      FASCIA LATA GRAFT; BY STRIPPER                                        N     3
                      20922    2                      FASCIA LATA GRAFT; BY INCISION AND AREA EXPOSURE,                     N     3
                      20922    7                      FASCIA LATA GRAFT; BY INCISION AND AREA EXPOSURE,                     N     3
                      20922    F                      FASCIA LATA GRAFT; BY INCISION AND AREA EXPOSURE,                     N     3
                      20924    2                      TENDON GRAFT, FROM A DISTANCE                                         N     3
                      20924    7                      TENDON GRAFT, FROM A DISTANCE                                         N     3
                      20924    8                      TENDON GRAFT, FROM A DISTANCE                                         N     3
                      20924    F                      TENDON GRAFT, FROM A DISTANCE                                         N     3
                      20926    2                      TISSUE GRAFTS, OTHER                                                  N     3
                      20926    7                      TISSUE GRAFTS, OTHER                                                  N     3
                      20926    F                      TISSUE GRAFTS, OTHER                                                  N     3
                      20930    2                      ALLOGRAFT FOR SPINE SURGERY ONLY; MORSELIZED                          N     3
                      20930    8                      ALLOGRAFT FOR SPINE SURGERY ONLY; STRUCTURAL                          N     3
                      20931    2                      ALLOGRAFT FOR SPINE SURGERY ONLY; STRUCTURAL                          N     3
                      20931    8                      ALLOGRAFT FOR SPINE SURGERY ONLY; STRUCTURAL                          N     3
                      20936    2                      AUTOGRAFT FOR SPINE SURGERY ONLY; OBTAINED FROM SAME INCISION         N     3
                      20936    8                      AUTOGRAFT FOR SPINE SURGERY ONLY; OBTAINED FROM SAME INCISION         N     3
                      20937    2                      AUTOGRAFT FOR SPINE SURGERY ONLY; MORSELIZED                          N     3
                      20937    8                      AUTOGRAFT FOR SPINE SURGERY ONLY; MORSELIZED                          N     3
                      20938    2                      AUTOGRAFT FOR SPINE SURGERY ONLY; STRUCTURAL                          N     3
                      20938    8                      AUTOGRAFT FOR SPINE SURGERY ONLY; STRUCTURAL                          N     3
                      20950    2                      MONITORING OF INTERSTITIAL FLUID PRESS (EG WICK CA                    N     3
                      20950    7                      MONITORING OF INTERSTITIAL FLUID PRESS (EG WICK CA                    N     3
                      20955    2                      BONE GRAFT WITH MICROVASCULAR ANASTOMOSIS; FIBULA                     N     3
                      20955    7                      BONE GRAFT WITH MICROVASCULAR ANASTOMOSIS; FIBULA                     N     3
                      20955    8                      BONE GRAFT WITH MICROVASCULAR ANASTOMOSIS; FIBULA                     N     3
                      20956    2                      BONE GRAFT W/MICROVASCULAR ANASTOMOSIS; ILIAC CREST                   N     3
                      20956    7                      BONE GRAFT W/MICROVASCULAR ANASTOMOSIS; ILIAC CREST                   N     3
                      20956    8                      BONE GRAFT W/MICROVASCULAR ANASTOMOSIS; ILIAC CREST                   N     3
                      20957    2                      BONE GRAFT W/MICROVASCULAR ANASTOMOSIS; METATARSAL                    N     3
                      20957    7                      BONE GRAFT W/MICROVASCULAR ANASTOMOSIS; METATARSAL                    N     3
                      20957    8                      BONE GRAFT W/MICROVASCULAR ANASTOMOSIS; METATARSAL                    N     3
                      20960    7                      BONE GRAFT WITH MICROVASCULAR ANASTOMOSIS; RIB                        N     3
                      20962    2                      BONE GRAFT WITH MICROVASCULAR ANASTOMOSIS;OTHER THAN FIBULA,ILIAC     N     3
                      20962    7                      BONE GRAFT WITH MICROVASCULAR ANASTOMOSIS; OTHER B                    N     3
                      20962    8                      BONE GRAFT WITH MICROVASCULAR ANASTOMOSIS;OTHER THAN FIBULA,ILIAC     N     3
                      20969    2                      FREE OSTEOCUTANEOUS FLAP W/MICROVASCULAR ANAST;OTH                    N     3
                      20969    7                      FREE OSTEOCUTANEOUS FLAP W/MICROVASCULAR ANAST;OTH                    N     3
                      20969    8                      FREE OSTEOCUTANEOUS FLAP W/MICROVASCULAR ANAST;OTH                    N     3
                      20970    2                      FREE OSTEOCUTANEOUS FLAP WITH MICROVASCULAR ANASTOMOSIS;ILIAC CRE     N     3
                      20970    7                      FREE OSTEOCUTANEOUS FLAP WITH MICROVASCULAR ANASTO                    N     3
                      20970    8                      FREE OSTEOCUTANEOUS FLAP WITH MICROVASCULAR ANASTO                    N     3
                      20971    7                      FREE OSTEOCUTANEOUS FLAP W/MICROVASCULAR ANASTOMOS                    N     3
                      20972    7                      FREE OSTEOCUTANEOUS FLAP W/MICROVASCULAR ANASTOMOS                    N     3
                      20973    7                      FREE OSTEOCUTANEOUS FLAP W/MICRO ANASTOM GR TOE                       N     3




Updated: 09/22/2006                                                                                                                    Page: 30 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      20975    2                      ELECTRICAL STIMULATION TO AID BONE HEALING; INVASI                    N     3
                      20975    F                      ELECTRICAL STIMULATION TO AID BONE HEALING; INVASI                    N     3
                      20979    2                      LOW INTENSITY ULTRASOUND STIMULATION TO AID BONE HEALING NONINVAS     N     3
                      20982    4                      ABLATION BONE TUMOR(S) EG OSTEOID OSTEOMA METASTASIS RADIOFREQUEN     N     3
                      20999    7                      UNLISTED PROCEDURE, MUSCULOSKELETAL SYSTEM, GENERA                    N     3
                      21010    2                      ARTHROTOMY, TEMPOROMANDIBULAR JOINT; UNILATERAL                       N     3
                      21010    7                      ARTHROTOMY, TEMPOROMANDIBULAR JOINT; UNILATERAL                       N     3
                      21010    F                      ARTHROTOMY, TEMPOROMANDIBULAR JOINT; UNILATERAL                       N     3
                      21015    2                      (SKULL, FACIAL BONES AND TEMPOROMANDIBULAR JOINT)                     N     3
                      21015    7                      (SKULL, FACIAL BONES AND TEMPOROMANDIBULAR JOINT)                     N     3
                      21015    F                      (SKULL, FACIAL BONES AND TEMPOROMANDIBULAR JOINT)                     N     3
                      21025    2                      EXCISN BONE (FOR OSTEMYLITIS/BONE ABSCESS); MANDIB                    N     3
                      21025    7                      EXCISN BONE (FOR OSTEMYLITIS/BONE ABSCESS); MANDIB                    N     3
                      21025    8                      EXCISN BONE (FOR OSTEMYLITIS/BONE ABSCESS); MANDIB                    N     3
                      21025    F                      EXCISN BONE (FOR OSTEMYLITIS/BONE ABSCESS); MANDIB                    N     3
                      21026    7                      EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE AB                    N     3
                      21026    F                      EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE AB                    N     3
                      21029    7                      REMOVAL BY CONTOURING OF BENIGN TUMOR OF FACIAL BO                    N     3
                      21029    F                      REMOVAL BY CONTOURING OF BENIGN TUMOR OF FACIAL BO                    N     3
                      21030    2                      EXCISION OF BENIGN TUMOR OR CYST OF FACIAL BONE OT                    N     3
                      21030    7                      EXCISION OF BENIGN TUMOR OR CYST OF FACIAL BONE OT                    N     3
                      21031    2                      EXCISION OF TORUS MANDIRULARIS                                        N     3
                      21031    7                      EXCISION OF TORUS MANDIBULARIS                                        N     3
                      21032    7                      EXCISION OF MAXILLARY TORUS PALATINUS                                 N     3
                      21034    2                      EXCISION OF MALIGNANT TUMOR OF FACIAL BONE OTHER T                    N     3
                      21034    7                      EXCISION OF MALIGNANT TUMOR OF FACIAL BONE OTHER T                    N     3
                      21034    F                      EXCISION OF MALIGNANT TUMOR OF FACIAL BONE OTHER T                    N     3
                      21040    2                      EXCISION OF BENIGN CYST OR TUMOR OF MANDIBLE; SIMP                    N     3
                      21040    7                      EXCISION OF BENIGN CYST OR TUMOR OF MANDIBLE; SIMP                    N     3
                      21040    F                      EXCISION OF BENIGN CYST OR TUMOR OF MANDIBLE; SIMP                    N     3
                      21041    7                      EXCISION OF BENIGN CYST OR TUMOR OF MANDIBLE; COMP                    N     3
                      21044    2                      EXCISION OF MALIGNANT TUMOR OF MANDIBLE;                              N     3
                      21044    7                      EXCISION OF MALIGNANT TUMOR OF MANDIBLE;                              N     3
                      21044    F                      EXCISION OF MALIGNANT TUMOR OF MANDIBLE;                              N     3
                      21045    2                      EXCISION OF MALIGNANT TUMOR OF MANDIBLE; RADICAL R                    N     3
                      21045    7                      EXCISION OF MALIGNANT TUMOR OF MANDIBLE; RADICAL R                    N     3
                      21046    2                      EXCISION BENIGN TUMOR/CYST MANDIBLE INTRA ORAL OSTEOTOMY              N     3
                      21047    2                      EXCIS BENIGN TUMOR/CYST MANDIBLE EXTRA ORAL OSTEOTOMY                 N     3
                      21048    2                      EXC BENIGN TUMOR/CYST MAXILLA INTRA ORAL OSTEOTOMY                    N     3
                      21049    2                      EXCIS BENIGN TUMOR/CYST MAXILLA EXTRA ORAL OSTEOTOMY                  N     3
                      21050    2                      ARTHRECTOMY, TEMPOROMANDIBULAR JOINT; UNILATERAL                      N     3
                      21050    7                      ARTHRECTOMY, TEMPOROMANDIBULAR JOINT; UNILATERAL                      N     3
                      21050    8                      ARTHRECTOMY, TEMPOROMANDIBULAR JOINT; UNILATERAL                      N     3
                      21050    F                      ARTHRECTOMY, TEMPOROMANDIBULAR JOINT; UNILATERAL                      N     3
                      21060    2                      MENISCECTOMY, TEMPOROMANDIBULAR JOINT; UNILATERAL                     N     3
                      21060    7                      MENISCECTOMY, TEMPOROMANDIBULAR JOINT; UNILATERAL                     N     3
                      21060    8                      MENISCECTOMY, TEMPOROMANDIBULAR JOINT; UNILATERAL                     N     3




Updated: 09/22/2006                                                                                                                    Page: 31 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      21060    F                      MENISCECTOMY, TEMPOROMANDIBULAR JOINT; UNILATERAL                     N     3
                      21070    2                      CORONOIDECTOMY (SEPARATE PROCEDURE); UNILATERAL                       N     3
                      21070    7                      CORONOIDECTOMY (SEPARATE PROCEDURE); UNILATERAL                       N     3
                      21070    F                      CORONOIDECTOMY (SEPARATE PROCEDURE); UNILATERAL                       N     3
                      21076    2                      IMPRESSION & CUSTOM PREPARATION;SURGICAL OBTURATOR PROSTHESIS         N     3
                      21077    2                      IMPRESSION & CUSTOM PREPARATION ORBITAL PROSTHESE                     N     3
                      21079    2                      IMPRESSION AND CUSTOM PREPARATION;INTERIM OBTURATOR PROSTHESIS        N     3
                      21079    7                      (SKULL, FACIAL BONES AND TEMPOROMANDIBULAR JOINT)                     N     3
                      21079    8                      IMPRESSION AND CUSTOM PREPARATION;INTERIM OBTURATOR PROSTHESIS        N     3
                      21080    2                      IMPRESSION AND CUSTOM PREPARATION;DEFINITIVE OBTRUATOR PROSTHESIS     N     3
                      21080    7                      IMPRESSION AND CUSTOM PREPARATION;                                    N     3
                      21080    8                      IMPRESSION AND CUSTOM PREPARATION;DEFINITIVE OBTURATOR PROSTHESIS     N     3
                      21081    2                      IMPRESSION AND CUSTOM PREPARATION;MANDIBULAR RESECTION PROSTHESIS     N     3
                      21081    7                      IMPRESSION AND CUSTOM PREPARATION;                                    N     3
                      21081    8                      IMPRESSION AND CUSTOM PREPARATION;MANDIBULAR RESECTION PROSTHESIS     N     3
                      21082    2                      IMPRESSION AND CUSTOM PREPARATION;PALATAL AUGMENTATION PROSTHESIS     N     3
                      21082    7                      IMPRESSION AND CUSTOM PREPARATION;                                    N     3
                      21082    8                      IMPRESSION AND CUSTOM PREPARATION;PALATAL AUGMENTATION PROSTHESIS     N     3
                      21083    2                      IMPRESSION AND CUSTOM PREPARATION;PALATAL LIFT PROSTHESIS             N     3
                      21083    7                      IMPRESSION AND CUSTOM PREPARATION;                                    N     3
                      21083    8                      IMPRESSION AND CUSTOM PREPARATION;PALATAL LIFT PROSTHESIS             N     3
                      21085    2                      IMPRESSION AND CUSTOM PREPARATION;ORAL SURGICAL SPLINT                N     3
                      21085    7                      IMPRESSION AND CUSTOM PREPARATION;                                    N     3
                      21086    7                      IMPRESSION AND CUSTOM PREPARATION;                                    N     3
                      21087    7                      IMPRESSION AND CUSTOM PREPARATION;                                    N     3
                      21088    7                      IMPRESSION AND CUSTOM PREPARATION;                                    N     3
                      21089    7                      UNLISTED MAXILLOFACIAL PROSTHETIC PROCEDURE                           N     3
                      21100    2                      APPLICATION OF HALO TYPE APPLIANCE FOR MAXILLOFACI                    N     3
                      21100    7                      APPLICATION OF HALO TYPE APPLIANCE FOR MAXILLOFACI                    N     3
                      21100    F                      APPLICATION OF HALO TYPE APPLIANCE FOR MAXILLOFACI                    N     3
                      21110    2                      APPLICATION OF INTERDENTAL FIXATION DEVICE FOR CON                    N     3
                      21110    7                      APPLICATION OF INTERDENTAL FIXATION DEVICE FOR CON                    N     3
                      21116    2                      INJECTION PROC. FOR TEMPOROMANDIBULAR ARTHROTOMGRA                    N     3
                      21120    7                      (SKULL, FACIAL BONES AND TEMPOROMANDIBULAR JOINT)                     N     3
                      21121    7                      GENIOPLASTY;                                                          N     3
                      21122    7                      GENIOPLASTY;                                                          N     3
                      21122    F                      GENIOPLASTY;                                                          N     3
                      21123    7                      GENIOPLASTY;                                                          N     3
                      21123    F                      GENIOPLASTY;                                                          N     3
                      21125    7                      AUGMENTATION, MANDIBULAR BODY OR ANGLE;                               N     3
                      21127    7                      AUGMENTATION, MANDIBULAR BODY OR ANGLE;                               N     3
                      21127    F                      AUGMENTATION, MANDIBULAR BODY OR ANGLE;                               N     3
                      21137    7                      REDUCTION FOREHEAD;                                                   N     3
                      21138    7                      REDUCTION FOREHEAD;                                                   N     3
                      21139    7                      REDUCTION FOREHEAD;                                                   N     3
                      21141    2                      RECONSTRUCTION MIDFACE; WITHOUT BONE GRAFT                            N     3
                      21141    7                      RECONSTRUCTION MIDFACE;WITHOUT BONE GRAFT                             N     3




Updated: 09/22/2006                                                                                                                    Page: 32 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      21141    8                      RECONSTRUCTION MIDFACE; WITHOUT BONE GRAFT                            N     3
                      21142    2                      RECONSTRUCTION MIDFACE; TWO PIECES; WITHOUT BONE GRAFT                N     3
                      21142    8                      RECONSTRUCITON MIDFACE; TWO PIECES; WITHOUT BONE GRAFT                N     3
                      21143    2                      RECONSTRUCITON MIDFACE; 3 OR MORE PIECES, WITHOUT BONE GRAFT          N     3
                      21143    8                      RECONSTRUCTION MIDFACE; 3 OR MORE PIECES; WITHOUT BONE GRAFT          N     3
                      21144    7                      RECONSTRUCTION MIDFACE, LEFORT I;                                     N     3
                      21145    7                      RECONSTRUCTION MIDFACE, LEFORT I;                                     N     3
                      21146    7                      RECONSTRUCTION MIDFACE, LEFORT I;                                     N     3
                      21147    7                      RECONSTRUCTION MIDFACE, LEFORT I;                                     N     3
                      21150    7                      RECONSTRUCTION MIDFACE, LEFORT II;                                    N     3
                      21151    7                      RECONSTRUCTION MIDFACE, LEFORT II;                                    N     3
                      21154    7                      RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL),                    N     3
                      21155    7                      RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL),                    N     3
                      21159    7                      RECONSTRUCTION MIDFACE, LEFORT III (EXTRA AND INTR                    N     3
                      21160    7                      RECONSTRUCTION MIDFACE, LEFORT III (EXTRA AND INTR                    N     3
                      21172    7                      RECONSTRUCTION SUPERIOR-LATERAL ORBITAL RIM AND LO                    N     3
                      21175    2                      RECONSTRUCTION,BIFRONTAL,SUPERIOR-LATERAL ORBITAL RIMS AND LOWER      N     3
                      21175    7                      RECON,BI-FRONTAL,SUP-LAT ORB RIMS AND LOW FRHEAD                      N     3
                      21175    8                      RECONSTRUCTION,BIFRONTAL,SUPERIOR-LATERAL ORBITAL RIMS AND LOWER      N     3
                      21179    2                      RECONSTRUCTION, ENTIRE OR MAJORITY OF FOREHEAD AND                    N     3
                      21179    7                      RECONSTRUCTION, ENTIRE OR MAJORITY OF FOREHEAD AND                    N     3
                      21180    7                      RECONSTRUCTION, ENTIRE OR MAJORITY OF FOREHEAD AND                    N     3
                      21181    7                      REMOVAL BY CONTOURING OF BENIGN TUMOR OF CRANIAL B                    N     3
                      21181    F                      REMOVAL BY CONTOURING OF BENIGN TUMOR OF CRANIAL B                    N     3
                      21182    2                      RECONSTRUCTION OF ORBITAL WALLS, RIMS, FOREHEAD, N                    N     3
                      21182    7                      RECONSTRUCTION OF ORBITAL WALLS, RIMS, FOREHEAD, N                    N     3
                      21183    7                      RECONSTRUCTION OF ORBITAL WALLS, RIMS, FOREHEAD, N                    N     3
                      21184    7                      RECONSTRUCTION OF ORBITAL WALLS, RIMS, FOREHEAD, N                    N     3
                      21188    7                      RECONSTRUCTION MIDFACE, OSTEOTOMIES (OTHER THAN LE                    N     3
                      21193    2                      RECONSTRUCTION OF MANDIBULAR RAMI,HORIZ/VERT,C/L OSTETMY W/O GRFT     N     3
                      21193    7                      RECONSTRUCTION OF MANDIBULAR RAMUS, HORIZONTAL, VERTICAL              N     3
                      21194    7                      RECONSTRUCTION OF MANDIBULAR RAMUS, HORIZONTAL, VERTICAL,C            N     3
                      21195    7                      RECONSTRUCTION OF MANDIBULAR RAMUS, SAGITTAL SPLIT                    N     3
                      21196    2                      RECONSTRUCTION OF MANDIBULAR RAMUS, SAGITTAL SPLIT                    N     3
                      21196    7                      RECONSTRUCTION OF MANDIBULAR RAMUS, SAGITTAL SPLIT                    N     3
                      21198    2                      OSTEOTOMY, MANDIBLE, SEGMENTAL                                        N     3
                      21198    7                      OSTEOTOMY, MANDIBLE, SEGMENTAL                                        N     3
                      21199    2                      OSTEOTOMY MANDIBLE SEGMENT.W/GENIOGLOSSESADVANCEMENT                  N     3
                      21206    2                      OSTEOPLASTY FOR PROGNATHISM, MICROGNATHISM, OR APE                    N     3
                      21206    7                      OSTEOPLASTY FOR PROGNATHISM, MICROGNATHISM, OR APE                    N     3
                      21206    F                      OSTEOPLASTY FOR PROGNATHISM, MICROGNATHISM, OR APE                    N     3
                      21208    2                      OSTEOPLASTY, FACIAL BONES                                             N     3
                      21208    7                      OSTEOPLASTY, FACIAL BONES                                             N     3
                      21208    F                      OSTEOPLASTY, FACIAL BONES                                             N     3
                      21209    7                      OSTEOPLASTY, FACIAL BONES                                             N     3
                      21209    F                      OSTEOPLASTY, FACIAL BONES                                             N     3
                      21210    2                      GRAFT, BONE; NASAL, MAXILLARY AND MALAR AREAS                         N     3




Updated: 09/22/2006                                                                                                                    Page: 33 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      21210    7                      GRAFT, BONE; NASAL, MAXILLARY AND MALAR AREAS          N     3
                      21210    F                      GRAFT, BONE; NASAL, MAXILLARY AND MALAR AREAS          N     3
                      21215    2                      GRAFT, BONE; MANDIBLE (INCLUDES OBTAINING GRAFT)       N     3
                      21215    7                      GRAFT, BONE; MANDIBLE (INCLUDES OBTAINING GRAFT)       N     3
                      21215    F                      GRAFT, BONE; MANDIBLE (INCLUDES OBTAINING GRAFT)       N     3
                      21230    2                      GRAFT; RIB CARTILAGE, AUTOGENOUS, TO FACE, CHIN, N     N     3
                      21230    7                      GRAFT; RIB CARTILAGE, AUTOGENOUS, TO FACE, CHIN, N     N     3
                      21230    8                      GRAFT; RIB CARTILAGE, AUTOGENOUS, TO FACE, CHIN, N     N     3
                      21230    F                      GRAFT; RIB CARTILAGE, AUTOGENOUS, TO FACE, CHIN, N     N     3
                      21235    2                      GRAFT; EAR CARTILAGE TO NOSE OR EAR                    N     3
                      21235    7                      GRAFT; EAR CARTILAGE TO NOSE OR EAR                    N     3
                      21235    8                      GRAFT; EAR CARTILAGE TO NOSE OR EAR                    N     3
                      21235    F                      GRAFT; EAR CARTILAGE TO NOSE OR EAR                    N     3
                      21240    2                      ARTHROPLASTY, TEMPOROMANDIBULAR JOINT                  N     3
                      21240    7                      ARTHROPLASTY, TEMPOROMANDIBULAR JOINT                  N     3
                      21240    8                      ARTHROPLASTY, TEMPOROMANDIBULAR JOINT                  N     3
                      21240    F                      ARTHROPLASTY, TEMPOROMANDIBULAR JOINT                  N     3
                      21241    2                      ARTHROPLASTY, TEMPOROMANDIBULAR JOINT; BILATERAL       N     3
                      21241    7                      ARTHROPLASTY, TEMPOROMANDIBULAR JOINT; BILATERAL       N     3
                      21242    2                      ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, W/ALLOPLAST     N     3
                      21242    7                      ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, W/ALLOPLAST     N     3
                      21242    F                      ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, W/ALLOPLAST     N     3
                      21243    7                      ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH PROSTH     N     3
                      21243    F                      ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH PROSTH     N     3
                      21244    2                      RECONSTRUCTION OF MANDIBLE, EXTRAORAL, WITH TRANSO     N     3
                      21244    7                      RECONSTRUCTION OF MANDIBLE, EXTRAORAL, WITH TRANSO     N     3
                      21244    F                      RECONSTRUCTION OF MANDIBLE, EXTRAORAL, WITH TRANSO     N     3
                      21245    7                      RECONSTRUCTION OF MANDIBLE OR MAXILLA, SUBPERIOSTE     N     3
                      21245    F                      RECONSTRUCTION OF MANDIBLE OR MAXILLA, SUBPERIOSTE     N     3
                      21246    7                      RECONSTRUCTION OF MANDIBLE OR MAXILLA, SUBPERIOSTE     N     3
                      21246    F                      RECONSTRUCTION OF MANDIBLE OR MAXILLA, SUBPERIOSTE     N     3
                      21247    7                      RECONSTRUCTION OF MANDIBULAR CONDYLE WITH BONE AND     N     3
                      21248    7                      RECONSTRUCTION OF MANDIBLE OR MAXILLA, ENDOSTEAL I     N     3
                      21248    F                      RECONSTRUCTION OF MANDIBLE OR MAXILLA, ENDOSTEAL I     N     3
                      21249    7                      RECONSTRUCTION OF MANDIBLE OR MAXILLA, ENDOSTEAL I     N     3
                      21249    F                      RECONSTRUCTION OF MANDIBLE OR MAXILLA, ENDOSTEAL I     N     3
                      21255    7                      RECONSTRUCTION OF ZYGOMATIC ARCH AND GLENOID FOSSA     N     3
                      21256    2                      RECONSTRUCTION OF ORBIT WITH OSTEOTOMIES (EXTRACRA     N     3
                      21256    7                      RECONSTRUCTION OF ORBIT WITH OSTEOTOMIES (EXTRACRA     N     3
                      21260    2                      PERIORBITAL OSTEOTOMIES FOR ORBITAL HYPERTELORISM,     N     3
                      21260    7                      PERIORBITAL OSTEOTOMIES FOR ORBITAL HYPERTELORISM,     N     3
                      21261    7                      ORBITAL HYPERTELORISM CORRECTION (PERIORBITAL) OST     N     3
                      21263    7                      ORBITAL HYPERTELORISM CORRECTION (PERIORBITAL) OST     N     3
                      21267    7                      ORBITAL REPOSITIONING, PERIORBITAL OSTEOTOMIES, UN     N     3
                      21267    F                      ORBITAL REPOSITIONING, PERIORBITAL OSTEOTOMIES, UN     N     3
                      21268    7                      ORBITAL REPOSITIONING, PERIORBITAL OSTEOTOMIES, UN     N     3
                      21270    7                      RECONSTRUCTION FOR TREACHER COLLINS SYNDROME (PERI     N     3




Updated: 09/22/2006                                                                                                     Page: 34 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      21270    F                      RECONSTRUCTION FOR TREACHER COLLINS SYNDROME (PERI     N     3
                      21275    2                      SECONDARY REVISION OF ORBITOCRANIOFACIAL RECONSTRU     N     3
                      21275    7                      SECONDARY REVISION OF ORBITOCRANIOFACIAL RECONSTRU     N     3
                      21275    F                      SECONDARY REVISION OF ORBITOCRANIOFACIAL RECONSTRU     N     3
                      21280    7                      MEDIAL CANTHOPLASTY                                    N     3
                      21280    F                      MEDIAL CANTHOPLASTY                                    N     3
                      21282    2                      LATERAL CANTHOPEXY                                     N     3
                      21282    7                      LATERAL CANTHOPEXY                                     N     3
                      21282    F                      LATERAL CANTHOPEXY                                     N     3
                      21295    7                      REDUCT OF MASSETER MUSCLE(EG, TREAT OF BENIGN MASS     N     3
                      21295    F                      REDUCT OF MASSETER MUSCLE(EG, TREAT OF BENIGN MASS     N     3
                      21296    7                      REDUCT OF MASSETER MUSCLE(EG, TREAT OF BENIGN MASS     N     3
                      21296    F                      REDUCT OF MASSETER MUSCLE(EG, TREAT OF BENIGN MASS     N     3
                      21299    7                      UNLISTED CRANIOFACIAL AND MAXILLOFACIAL PROCEDURE      N     3
                      21300    7                      TREATMENT OF CLOSED SKULL FRACTURE WITHOUT OPERATI     N     3
                      21300    F                      TREATMENT OF CLOSED SKULL FRACTURE WITHOUT OPERATI     N     3
                      21310    2                      TREATMENT OF CLOSED OR OPEN NASAL FRACTURE WITHOUT     N     3
                      21310    7                      TREATMENT OF CLOSED OR OPEN NASAL FRACTURE WITHOUT     N     3
                      21310    F                      TREATMENT OF CLOSED OR OPEN NASAL FRACTURE WITHOUT     N     3
                      21315    2                      MANIPULATIVE TREATMENT, NASAL BONE FRACTURE, WITHO     N     3
                      21315    7                      MANIPULATIVE TREATMENT, NASAL BONE FRACTURE, WITHO     N     3
                      21315    F                      MANIPULATIVE TREATMENT, NASAL BONE FRACTURE, WITHO     N     3
                      21320    2                      MANIPULATIVE TREATMENT, NASAL BONE FRACTURE, WITH      N     3
                      21320    7                      MANIPULATIVE TREATMENT, NASAL BONE FRACTURE, WITH      N     3
                      21320    F                      MANIPULATIVE TREATMENT, NASAL BONE FRACTURE, WITH      N     3
                      21325    2                      OPEN TREATMENT OF NASAL FRACTURE; UNCOMPLICATED        N     3
                      21325    7                      OPEN TREATMENT OF NASAL FRACTURE; UNCOMPLICATED        N     3
                      21325    F                      OPEN TREATMENT OF NASAL FRACTURE; UNCOMPLICATED        N     3
                      21330    2                      OPEN TREATMENT OF NASAL FRACTURE;COMPLICATED,WITH      N     3
                      21330    7                      OPEN TREATMENT OF NASAL FRACTURE;COMPLICATED,WITH      N     3
                      21330    F                      OPEN TREATMENT OF NASAL FRACTURE;COMPLICATED,WITH      N     3
                      21334    7                      OPEN TRTMNT OF COMPLICATED (EF, COMMINUTED OR INVO     N     3
                      21335    2                      OPEN TREATMENT OF NASAL FRACTURE;WITH CONCOMITANT      N     3
                      21335    7                      OPEN TREATMENT OF NASAL FRACTURE;WITH CONCOMITANT      N     3
                      21335    F                      OPEN TREATMENT OF NASAL FRACTURE;WITH CONCOMITANT      N     3
                      21336    2                      OPEN TREATMENT OF NASAL SEPTAL FRACTURE, WITH OR W     N     3
                      21336    7                      OPEN TRTMNT OF NASAL SEPTAL FRACTURE, W OR W/O STA     N     3
                      21336    F                      OPEN TREATMENT OF NASAL SEPTAL FRACTURE, WITH OR W     N     3
                      21337    2                      TREATMENT OF CLOSED NASAL SEPTAL FRACTURE              N     3
                      21337    7                      TREATMENT OF CLOSED NASAL SEPTAL FRACTURE              N     3
                      21337    F                      TREATMENT OF CLOSED NASAL SEPTAL FRACTURE              N     3
                      21338    2                      OPEN TREATMENT OF NASOETHMOID FRACTURE W/O EXTERNA     N     3
                      21338    7                      OPEN TREATMENT OF NASOETHMOID FRACTURE W/O EXTERNA     N     3
                      21338    F                      OPEN TREATMENT OF NASOETHMOID FRACTURE W/O EXTERNA     N     3
                      21339    2                      OPEN TREATMENT OF NASOETHMOID FRACTURE WITH EXTERN     N     3
                      21339    7                      OPEN TREATMENT OF NASOETHMOID FRACTURE WITH EXTERN     N     3
                      21339    F                      OPEN TREATMENT OF NASOETHMOID FRACTURE WITH EXTERN     N     3




Updated: 09/22/2006                                                                                                     Page: 35 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      21340    2                      TREATMENT OF CLOSED/OPEN NASOETHMOID COMPLEX FRACT     N     3
                      21340    7                      TREATMENT OF CLOSED/OPEN NASOETHMOID COMPLEX FRACT     N     3
                      21340    F                      TREATMENT OF CLOSED/OPEN NASOETHMOID COMPLEX FRACT     N     3
                      21343    2                      OPEN TREATMENT OF CLOSED OR OPEN DEPRESSED FRONTAL     N     3
                      21343    7                      OPEN TREATMENT OF CLOSED OR OPEN DEPRESSED FRONTAL     N     3
                      21344    2                      OPEN TREATMENT OF COMPLICATED (EG, COMMINUTED OR I     N     3
                      21345    2                      TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFOR     N     3
                      21345    7                      TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFOR     N     3
                      21345    F                      TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFOR     N     3
                      21346    2                      OPEN TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (     N     3
                      21346    7                      OPEN TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (     N     3
                      21346    8                      OPEN TREAT NASOMAX FRAC LEFORT II TYPE W INT FIX       N     3
                      21347    2                      OPEN TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (     N     3
                      21347    7                      OPEN TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (     N     3
                      21348    2                      OPEN TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (     N     3
                      21348    7                      OPEN TRTMENT OF NASOMAZILLARY COMPLEX FRACTURE         N     3
                      21355    2                      MANIPULATIVE TREATMENT OF CLOSED OR OPEN FRACTURE      N     3
                      21355    7                      MANIPULATIVE TREATMENT OF CLOSED OR OPEN FRACTURE      N     3
                      21355    F                      MANIPULATIVE TREATMENT OF CLOSED OR OPEN FRACTURE      N     3
                      21356    2                      OPEN TREATMENT OF DEPRESSED ZYGOMATIC ARCH FRACTUR     N     3
                      21356    7                      OPEN TRTMENT OF DERESSED ZYGOMATIC ARCH FRACTURE       N     3
                      21360    2                      OPEN TREATMENT OF CLOSED OR OPEN DEPRESSED MALAR F     N     3
                      21360    7                      OPEN TREATMENT OF CLOSED OR OPEN DEPRESSED MALAR F     N     3
                      21360    8                      OPEN TREATMENT OF CLOSED OR OPEN DEPRESSED MALAR F     N     3
                      21365    2                      OPEN TREATMENT OF CLOSED OR OPEN COMPLICATED; MULT     N     3
                      21365    7                      OPEN TREATMENT OF CLOSED OR OPEN COMPLICATED; MULT     N     3
                      21366    2                      OPEN TREATMENT OF COMPLICATED (EG, COMMINUTED OR I     N     3
                      21366    7                      OPEN TRTMNT OF COMPLICATED (EG, COMINUTED OR INVOL     N     3
                      21380    7                      TREATMENT OF ORBITAL FLOOR ''BLOWOUT'' FRACTURE WI     N     3
                      21385    2                      OPEN TREATMENT OF ORBITAL FLOOR ''BLOWOUT'' FRACTU     N     3
                      21385    7                      OPEN TREATMENT OF ORBITAL FLOOR ''BLOWOUT'' FRACTU     N     3
                      21385    8                      OPEN TREATMENT OF ORBITAL FLOOR ''BLOWOUT'' FRACTU     N     3
                      21386    2                      OPEN TREATMENT OF ORBITAL FLOOR ''BLOWOUT'' FRACTU     N     3
                      21386    7                      OPEN TREATMENT OF ORBITAL FLOOR ''BLOWOUT'' FRACTU     N     3
                      21387    2                      OPEN TREATMENT OF ORBITAL FLOOR ''BLOWOUT'' FRACTU     N     3
                      21387    7                      OPEN TREATMENT OF ORBITAL FLOOR ''BLOWOUT'' FRACTU     N     3
                      21390    2                      OPEN TREATMENT OF ORBITAL FLOOR ''BLOWOUT'' FRACTU     N     3
                      21390    7                      OPEN TREATMENT OF ORBITAL FLOOR ''BLOWOUT'' FRACTU     N     3
                      21390    8                      OPEN TREATMENT OF ORBITAL FLOOR ''BLOWOUT'' FRACTU     N     3
                      21395    2                      OPEN TREATMENT OF ORBITAL FLOOR ''BLOWOUT'' FRACTU     N     3
                      21395    7                      OPEN TREATMENT OF ORBITAL FLOOR ''BLOWOUT'' FRACTU     N     3
                      21395    8                      OPEN TREATMENT OF ORBITAL FLOOR ''BLOWOUT'' FRACTU     N     3
                      21400    2                      TREATMENT OF FRACTURE OF ORBIT, EXCEPT ''BLOWOUT''     N     3
                      21400    F                      TREATMENT OF FRACTURE OF ORBIT, EXCEPT ''BLOWOUT''     N     3
                      21401    2                      TREATMENT OF FRACTURE OF ORBIT, EXCEPT ''BLOWOUT''     N     3
                      21401    7                      TREATMENT OF FRACTURE OF ORBIT, EXCEPT ''BLOWOUT''     N     3
                      21401    F                      TREATMENT OF FRACTURE OF ORBIT, EXCEPT ''BLOWOUT''     N     3




Updated: 09/22/2006                                                                                                     Page: 36 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      21406    2                      OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT ''BLOW                    N     3
                      21406    7                      OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT ''BLOW                    N     3
                      21407    2                      OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT ''BLOW                    N     3
                      21407    7                      OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT ''BLOW                    N     3
                      21408    2                      OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT ''BLOW                    N     3
                      21408    7                      OPEN TRTMNT OF FRACTURE OF ORBIT,EXCEPT BLOWOUT                       N     3
                      21421    2                      TREATMENT OF PALATAL OR ALVEOLAR RIDGE FRACTURES (                    N     3
                      21421    7                      TREATMENT OF PALATAL OR ALVEOLAR RIDGE FRACTURES (                    N     3
                      21421    8                      TREATMENT OF PALATAL OR ALVEOLAR RIDGE FRACTURES (                    N     3
                      21421    F                      TREATMENT OF PALATAL OR ALVEOLAR RIDGE FRACTURES (                    N     3
                      21422    2                      TREATMENT OF PALATAL OR ALVEOLAR RIDGE FRACTURES (                    N     3
                      21422    7                      TREATMENT OF PALATAL OR ALVEOLAR RIDGE FRACTURES (                    N     3
                      21423    2                      OPEN TREATMENT OF PALATAL OR MAXILLARY FRACTURE (L                    N     3
                      21423    7                      OPEN TRTMNT OF PALATAL OR MAZILLARY FRACTURE I TYP                    N     3
                      21431    2                      TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III T                    N     3
                      21431    7                      TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III T                    N     3
                      21432    2                      OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT                     N     3
                      21432    7                      OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT                     N     3
                      21433    2                      OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT                     N     3
                      21433    7                      OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT                     N     3
                      21435    2                      OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT                     N     3
                      21435    7                      OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT                     N     3
                      21436    2                      OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT                     N     3
                      21436    7                      OPEN TRTMNT OF CRANIOFACIL SEPARATION LEFORT 3 TYP                    N     3
                      21440    2                      MANIPULATIVE TREATMENT OF ALVEOLAR RIDGE FRACTURE                     N     3
                      21440    7                      MANIPULATIVE TREATMENT OF ALVEOLAR RIDGE FRACTURE                     N     3
                      21440    F                      MANIPULATIVE TREATMENT OF ALVEOLAR RIDGE FRACTURE                     N     3
                      21445    7                      OPEN TREATMENT OF ALVEOLAR RIDGE FRACTURE (SEPARAT                    N     3
                      21445    F                      OPEN TREATMENT OF ALVEOLAR RIDGE FRACTURE (SEPARAT                    N     3
                      21450    2                      TREATMENT OF CLOSED OR OPEN MANDIBULAR FRACTURE;WI                    N     3
                      21450    7                      TREATMENT OF CLOSED OR OPEN MANDIBULAR FRACTURE;WI                    N     3
                      21450    F                      TREATMENT OF CLOSED OR OPEN MANDIBULAR FRACTURE;WI                    N     3
                      21451    2                      TREATMENT OF CLOSED OR OPEN MANDIBULAR FRACTURE;WI                    N     3
                      21451    7                      TREATMENT OF CLOSED OR OPEN MANDIBULAR FRACTURE;WI                    N     3
                      21451    8                      TREATMENT OF CLOSED OR OPEN MANDIBULAR FRACTURE;WI                    N     3
                      21451    F                      TREATMENT OF CLOSED OR OPEN MANDIBULAR FRACTURE;WI                    N     3
                      21452    2                      TREATMENT OF OPEN MANDIBULAR FRACTURE W/O MANIPULA                    N     3
                      21452    7                      TREATMENT OF OPEN MANDIBULAR FRACTURE W/O MANIPULA                    N     3
                      21452    F                      TREATMENT OF OPEN MANDIBULAR FRACTURE W/O MANIPULA                    N     3
                      21453    2                      CLOSED TREATMENT OF MANDIBULAR FRACTURE WITH INTERDENTAL FIXATION     N     3
                      21453    7                      WITH MANIPULATION                                                     N     3
                      21453    F                      CLOSED TREATMENT OF MANDIBULAR FRACTURE WITH INTERDENTAL FIXATION     N     3
                      21454    2                      OPEN TREATMENT OF CLOSED OR OPEN MANDIBULAR FRACTU                    N     3
                      21454    7                      OPEN TREATMENT OF CLOSED OR OPEN MANDIBULAR FRACTU                    N     3
                      21454    8                      OPEN TREATMENT OF CLOSED OR OPEN MANDIBULAR FRACTU                    N     3
                      21454    F                      OPEN TREATMENT OF CLOSED OR OPEN MANDIBULAR FRACTU                    N     3
                      21461    2                      OPEN TRTM OF CLOSED OR OPEN MANDIBULAR FX                             N     3




Updated: 09/22/2006                                                                                                                    Page: 37 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                   PA IND PAC
                      21461    7                      OPEN TREATMENT OF CLOSED OR OPEN MANDIBULAR FRACTU        N     3
                      21461    F                      OPEN TRTM OF CLOSED OR OPEN MANDIBULAR FX                 N     3
                      21462    2                      OPEN TREATMENT OF CLOSED OR OPEN MANDIBULAR FRACTU        N     3
                      21462    7                      OPEN TREATMENT OF CLOSED OR OPEN MANDIBULAR FRACTU        N     3
                      21462    F                      OPEN TREATMENT OF CLOSED OR OPEN MANDIBULAR FRACTU        N     3
                      21465    2                      OPEN TREATMENT OF MANDIBULAR CONDYLAR FRACTURE            N     3
                      21465    7                      OPEN TREATMENT OF MANDIBULAR CONDYLAR FRACTURE            N     3
                      21465    F                      OPEN TREATMENT OF MANDIBULAR CONDYLAR FRACTURE            N     3
                      21470    2                      OPEN TREATMENT OF COMPLICATED CLOSED OR OPEN MANDI        N     3
                      21470    7                      OPEN REDUCTION OF COMPLICATED CLOSED OR OPEN MANDI        N     3
                      21480    2                      UNCOMPLICATED TREATMENT OF TEMPOROMANDIBULAR DISLO        N     3
                      21480    7                      UNCOMPLICATED TREATMENT OF TEMPOROMANDIBULAR DISLO        N     3
                      21480    F                      UNCOMPLICATED TREATMENT OF TEMPOROMANDIBULAR DISLO        N     3
                      21485    2                      COMPLICATED MANIPULATIVE TREATMENT OF TEMPOROMANDI        N     3
                      21485    7                      COMPLICATED MANIPULATIVE TREATMENT OF TEMPOROMANDI        N     3
                      21485    F                      COMPLICATED MANIPULATIVE TREATMENT OF TEMPOROMANDI        N     3
                      21490    2                      OPEN TREATMENT OF TEMPOROMANDIBULAR DISLOCATION           N     3
                      21490    7                      OPEN TREATMENT OF TEMPOROMANDIBULAR DISLOCATION           N     3
                      21490    F                      OPEN TREATMENT OF TEMPOROMANDIBULAR DISLOCATION           N     3
                      21495    2                      OPEN TREATMENT OF CLOSED OR OPEN HYOID FRACTURE           N     3
                      21495    7                      OPEN TREATMENT OF CLOSED OR OPEN HYOID FRACTURE           N     3
                      21497    2                      INTERDENTAL WIRING, FOR CONDITION OTHER THAN FRACTURE     N     3
                      21497    7                      INTERDENTAL WIRING, FOR CONDITION OTHER THAN FRACT        N     3
                      21497    F                      INTERDENTAL WIRING, FOR CONDITION OTHER THAN FRACTURE     N     3
                      21499    7                      UNLISTED PROCEDURE, HEAD                                  N     3
                      21501    2                      INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA;          N     3
                      21501    7                      INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA;          N     3
                      21501    F                      INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA;          N     3
                      21502    2                      INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA; W        N     3
                      21502    7                      INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA; W        N     3
                      21502    F                      INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA; W        N     3
                      21510    2                      INCISION, DEEP, WITH OPENING OF BONE CORTEX FOR OS        N     3
                      21510    7                      INCISION, DEEP, WITH OPENING OF BONE CORTEX FOR OS        N     3
                      21511    7                      INCISION, DEEP, WITH OPENING OF BONE CORTEX FOR OS        N     3
                      21550    2                      EXCISIONAL BIOPSY, SOFT TISSUES                           N     3
                      21550    7                      EXCISIONAL BIOPSY, SOFT TISSUES                           N     3
                      21555    2                      EXCISION BENIGN TUMOR; SUBCUTANEOUS                       N     3
                      21555    7                      EXCISION BENIGN TUMOR                                     N     3
                      21555    F                      EXCISION BENIGN TUMOR; SUBCUTANEOUS                       N     3
                      21556    2                      EXCISION BENIGN TUMOR; DEEP, SUBFASCIAL, INTRAMUSC        N     3
                      21556    7                      EXCISION BENIGN TUMOR; DEEP, SUBFASCIAL, INTRAMUSC        N     3
                      21556    F                      EXCISION BENIGN TUMOR; DEEP, SUBFASCIAL, INTRAMUSC        N     3
                      21557    2                      RAD RESEC TUMOR (MALIGN NEOPLSM) SFT TISS NCK THOR        N     3
                      21557    7                      RAD RESEC TUMOR (MALIGN NEOPLSM) SFR TISS NCK THOR        N     3
                      21600    2                      EXCISION OF RIB, PARTIAL                                  N     3
                      21600    7                      EXCISION OF RIB, PARTIAL                                  N     3
                      21600    F                      EXCISION OF RIB, PARTIAL                                  N     3




Updated: 09/22/2006                                                                                                        Page: 38 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      21610    2                      COSTOTRANSVERSECTOMY (SEPARATE PROCEDURE)              N     3
                      21610    7                      COSTOTRANSVERSECTOMY (SEPARATE PROCEDURE)              N     3
                      21610    8                      COSTOTRANSVERSECTOMY (SEPARATE PROCEDURE)              N     3
                      21610    F                      COSTOTRANSVERSECTOMY (SEPARATE PROCEDURE)              N     3
                      21615    2                      EXCISION FIRST AND/OR CERVICAL RIB FOR OUTLET COMP     N     3
                      21615    7                      EXCISION FIRST AND/OR CERVICAL RIB FOR OUTLET COMP     N     3
                      21615    8                      EXCISION FIRST AND/OR CERVICAL RIB FOR OUTLET COMP     N     3
                      21616    2                      EXCISION FIRST AND/OR CERVICAL RIB FOR OUTLET COMP     N     3
                      21616    7                      EXCISION FIRST AND/OR CERVICAL RIB FOR OUTLET COMP     N     3
                      21620    2                      OSTECTOMY OF STERNUM, PARTIAL                          N     3
                      21620    7                      OSTECTOMY OF STERNUM, PARTIAL                          N     3
                      21627    2                      STERNAL DEBRIDEMENT                                    N     3
                      21627    7                      ANESTHESIA,STERNAL DEBRIDEMENT                         N     3
                      21630    7                      RADICAL RESECTION OF STERNUM; FOR TUMOR                N     3
                      21632    7                      RADICAL RESECTION OF STERNUM FOR TUMOR; WITH MEDIA     N     3
                      21685    2                      HYOID MYOTOMY AND SUSPENSION                           N     3
                      21700    2                      DIVISION OF SCALENUS ANTICUS; WITHOUT RESECTION OF     N     3
                      21700    7                      DIVISION OF SCALENUS ANTICUS; WITHOUT RESECTION OF     N     3
                      21700    8                      DIVISION OF SCALENUS ANTICUS; WITHOUT RESECTION OF     N     3
                      21700    F                      DIVISION OF SCALENUS ANTICUS; WITHOUT RESECTION OF     N     3
                      21705    2                      DIVISION OF SCALENUS ANTICUS; WITH RESECTION OF CE     N     3
                      21705    7                      DIVISION OF SCALENUS ANTICUS; WITH RESECTION OF CE     N     3
                      21705    8                      DIVISION OF SCALENUS ANTICUS; WITH RESECTION OF CE     N     3
                      21720    2                      DIVISION OF STERNOCLEIDOMASTOID FOR TORTICOLLIS, O     N     3
                      21720    7                      DIVISION OF STERNOCLEIDOMASTOID FOR TORTICOLLIS, O     N     3
                      21720    8                      DIVISION OF STERNOCLEIDOMASTOID FOR TORTICOLLIS, O     N     3
                      21720    F                      DIVISION OF STERNOCLEIDOMASTOID FOR TORTICOLLIS, O     N     3
                      21725    2                      DIVISION OF STERNOCLEIDOMASTOID FOR TORTICOLLIS, O     N     3
                      21725    7                      DIVISION OF STERNOCLEIDOMASTOID FOR TORTICOLLIS, O     N     3
                      21725    F                      DIVISION OF STERNOCLEIDOMASTOID FOR TORTICOLLIS, O     N     3
                      21740    2                      RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATUM OR CARIN     N     3
                      21740    7                      RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATUM OR CARIN     N     3
                      21740    8                      RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATUM OR CARIN     N     3
                      21750    2                      CLOSURE OF STERNOTOMY SEPARATION WITH OR WITHOUT D     N     3
                      21750    7                      CLOSURE OF STERNOTOMY SEPARATION WITH OR WITHOUT D     N     3
                      21750    8                      CLOSURE OF STERNOTOMY SEPARATION WITH OR WITHOUT D     N     3
                      21800    2                      TREATMENT OF RIB FRACTURE; CLOSED, UNCOMPLICATED,      N     3
                      21800    F                      TREATMENT OF RIB FRACTURE; CLOSED, UNCOMPLICATED,      N     3
                      21805    2                      TREATMENT OF RIB FRACTURE; OPEN OR COMPLICATED, EA     N     3
                      21805    7                      TREATMENT OF RIB FRACTURE; OPEN OR COMPLICATED, EA     N     3
                      21805    F                      TREATMENT OF RIB FRACTURE; OPEN OR COMPLICATED, EA     N     3
                      21810    2                      TREATMENT OF RIB FRACTURE; CLOSED OR OPEN REQUIRIN     N     3
                      21810    7                      TREATMENT OF RIB FRACTURE; CLOSED OR OPEN REQUIRIN     N     3
                      21820    2                      TREATMENT OF STERNUM FRACTURE; CLOSED                  N     3
                      21820    F                      TREATMENT OF STERNUM FRACTURE; CLOSED                  N     3
                      21825    2                      TREATMENT OF STERNUM FRACTURE; OPEN                    N     3
                      21825    7                      TREATMENT OF STERNUM FRACTURE; OPEN                    N     3




Updated: 09/22/2006                                                                                                     Page: 39 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      21899    7                      UNLISTED PROCEDURE, NECK OR THORAX                                    N     3
                      21920    2                      BPSY SFT TISSUE BACK OR FLANK SUPERFICIAL                             N     3
                      21925    2                      BIOPSY SFT TISSUE BACK FLANK DEEP                                     N     3
                      21925    F                      BIOPSY SFT TISSUE BACK FLANK DEEP                                     N     3
                      21930    2                      EXCISION TUMOR SFT TISSUE BACK FLANK                                  N     3
                      21930    7                      EXCISION TUMOR SOFT TISSUE BACK FLANK                                 N     3
                      21930    F                      EXCISION TUMOR SFT TISSUE BACK FLANK                                  N     3
                      21935    2                      RADICAL RESECT TUMOR (MAL NEOP) SFT TISS BCK FLANK                    N     3
                      21935    F                      RADICAL RESECT TUMOR (MAL NEOP) SFT TISS BCK FLANK                    N     3
                      22010    2                      DELETED BY HCFA USE 21920                                             N     3
                      22100    2                      PART EXCSN OF POST VERTEBRL CMPNT FOR BONY LESION, 1 VRTBRT SGMNT     N     3
                      22100    7                      PARTIAL RESECTION OF VERTEBRAL COMPONENT, SPINOUS                     N     3
                      22101    2                      PARTIAL RESECTION OF VERTEBRAL COMPONENT, SPINOUS                     N     3
                      22101    7                      PARTIAL RESECTION OF VERTEBRAL COMPONENT, SPINOUS                     N     3
                      22102    2                      PARTIAL RESECTION OF VERTEBRAL COMPONENT, SPINOUS                     N     3
                      22102    7                      PARTIAL RESECTION OF VERTEBRAL COMPONENT, SPINOUS                     N     3
                      22103    2                      PARTIAL EXCISION OF POSTERIOR VERTEBRAL CMPONENT; EA ADDL SEGMENT     N     3
                      22103    8                      PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT,EA ADDL SEGMENT     N     3
                      22105    7                      PARTIAL RESECTION OF VERTEBRAL COMPONENT FOR TUMOR                    N     3
                      22106    7                      PARTIAL RESECTION OF VERTEBRAL COMPONENT FOR TUMOR                    N     3
                      22107    7                      PARTIAL RESECTION OF VERTEBRAL COMPONENT FOR TUMOR                    N     3
                      22110    2                      PART EXCISION OF VRTRBRL BONDY FOR BONY LESION, W/O DECOMPRESSION     N     3
                      22110    7                      PARTIAL EXCISION OF VERTEBRAE (CRATERIZATION);CERV                    N     3
                      22111    2                      PARTIAL EXCISION OF VERTEBRAE (CRATERIZATION)WITH                     N     3
                      22111    7                      PARTIAL EXCISION OF VERTEBRAE (CRATERIZATION)WITH                     N     3
                      22112    2                      PARTIAL EXCISION OF VERTEBRAE (CRATERIZATION); THO                    N     3
                      22112    7                      PARTIAL EXCISION OF VERTEBRAE (CRATERIZATION); THO                    N     3
                      22113    2                      PARTIAL EXCISION OF VERTEBRAE (CRATERIZATION); WIT                    N     3
                      22113    7                      PARTIAL EXCISION OF VERTEBRAE (CRATERIZATION); WIT                    N     3
                      22114    2                      PARTIAL EXCISION OF VERTEBRAE (CRATERIZATION); LUM                    N     3
                      22114    7                      PARTIAL EXCISION OF VERTEBRAE (CRATERIZATION); LUM                    N     3
                      22115    2                      PARTIAL EXCISION OF VERTEBRAE (CRATERIZATION); WIT                    N     3
                      22115    7                      PARTIAL EXCISION OF VERTEBRAE (CRATERIZATION); WIT                    N     3
                      22116    2                      PARTIAL EXCISION OF VERTEBRAL BODY;EA ADDL VERTEBRAL SEGMENT          N     3
                      22116    8                      PARTIAL EXCISION OF VERTEBRAL BODY; EA ADDL VERTEBRAL SEGMENT         N     3
                      22135    7                      (CERVICAL, THORACIC, AND LUMBAR SPINE)                                N     3
                      22140    7                      RECONSTRUCT SPINE W/BONE GRAFT SINGLE VERTEBRA                        N     3
                      22141    7                      RECONSTRUCT SPINE W/BONE GRAFT SINGLE VERTEBRA                        N     3
                      22142    7                      RECONSTRUCT SPINE W/BONE GRAFT OR METHYL LUMBAR                       N     3
                      22148    7                      HARVEST BONE AUTOGRAFT-RECONSTRUCT VERTEBRA                           N     3
                      22206    7                      OSTEOTOMY OF SPINE FOR CORRECTION FIXED DEFORMITY;                    N     3
                      22207    7                      OSTEOTOMY OF SPINE FOR CORRECTION FIXED DEFORMITY;                    N     3
                      22210    2                      OSTOTMY SPN POSTERIOR/OLATERAL, 1 VRTRBRL SGMT, CERVICAL              N     3
                      22210    7                      OSTEOTOMY CERV SPINE POST APPRCH SINGLE SEGMENT                       N     3
                      22210    8                      OSTEOTOMY CERV SPINE POST APPRCH SINGLE SEGMENT                       N     3
                      22212    2                      OSTOTMY SPN POST APRCH FOR CORR DFMTY SNGL SEC THO                    N     3
                      22212    7                      OSTEOTOMY THOR SPINE POST APPRCH SINGLE SEGMENT                       N     3




Updated: 09/22/2006                                                                                                                    Page: 40 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      22212    8                      OSTEOTOMY THOR SPINE POST APPRCH SINGLE SEGMENT                       N     3
                      22214    2                      OSTOTMY SPN POST APRCH FOR CORR DFMTY SNCL SEC LUM                    N     3
                      22214    7                      OSTEOTOMY LUMB SPINE POST APPRCH SINGLE SEGMENT                       N     3
                      22214    8                      OSTEOTOMY LUMB SPINE POST APPRCH SINGLE SEGMENT                       N     3
                      22216    2                      OSTEOTOMY OF SPINE; VERTEBRAL SEGMENT; EA. ADD'L SEGMENT              N     3
                      22216    8                      OSTEOTOMY OF SPINE; VERTEBRAL SEGMENT; EA. ADD'L SEGMENT              N     3
                      22220    2                      OSTOTMY SPN,INCL DSKCTMY, ANTER APPRCH, 1 VRTRBRL SGMT, CERVICAL      N     3
                      22220    7                      OSTEOTOMY CERV SPINE ANT APPRCH SINGLE SEGMENT                        N     3
                      22220    8                      OSTEOTOMY CERV SPINE ANT APPRCH SINGLE SEGMENT                        N     3
                      22222    2                      OSTOTMY SPN ANTR APRCH FOR CORR DFMTY SNGL SEC THO                    N     3
                      22222    7                      OSTEOTOMY THOR SPINE ANT APPROACH SINGLE SEGMENT                      N     3
                      22222    8                      OSTEOTOMY THOR SPINE ANT APPROACH SINGLE SEGMENT                      N     3
                      22224    2                      OSTOTMY SPN ANTR APRCH FOR CORR DFMTY SNGL SEC LUM                    N     3
                      22224    7                      OSTEOTOMY OF LUMB SPINE ANT APPRCH SINGLE SEGMENT                     N     3
                      22224    8                      OSTEOTOMY OF LUMBAR SPINE ONE SEGMNT ANT APPROACH                     N     3
                      22226    2                      OSTEOTOMY OF SPINE; EA. ADD'L SEGMENT                                 N     3
                      22226    8                      OSTEOTOMY OF SPINE; EA. ADD'L SEGMENT                                 N     3
                      22230    2                      OSTOTMY SPN FOR CRCTN DEFOR EACH ADDNTL SEG                           N     3
                      22250    7                      PROPHYLACTIC TREATMENT (PLATING AND/OR WIRING) WIT                    N     3
                      22251    7                      PROPHYLACTIC TREATMENT (PLATING AND/OR WIRING) WIT                    N     3
                      22305    2                      TREATMENT OF VERTEBRAL PROCESS FRACTURE, EACH                         N     3
                      22305    7                      TREATMENT OF VERTEBRAL PROCESS FRACTURE, EACH                         N     3
                      22305    F                      TREATMENT OF VERTEBRAL PROCESS FRACTURE, EACH                         N     3
                      22310    2                      CLOSED TRTMNT OF VRTRBRL FRACTURE, NO MANIP, INC. CAST/BRACE          N     3
                      22310    7                      TREATMENT OF VERTEBRAL BODY FRACTURE AND/OR DISLOC                    N     3
                      22310    F                      CLOSED TRTMNT OF VRTRBRL FRACTURE, NO MANIP, INC. CAST/BRACE          N     3
                      22315    2                      CLOSED TRTMT OF VRTRBRL FRCTR/DISLOC W/ CAST/BRAC W/-W/O ANSTHSIA     N     3
                      22315    7                      TREATMENT OF VERTEBRAL BODY FRACTURE AND/OR DISLOC                    N     3
                      22315    F                      CLOSED TRTMT OF VRTRBRL FRCTR/DISLOC W/ CAST/BRAC W/-W/O ANSTHSIA     N     3
                      22318    2                      OPEN TX/REDUC ODONTOID FRAC/DISLOC ANT APPROACH INC PLACE INT FIX     N     3
                      22318    7                      OPEN TX/REDUC ODONTOID FRAC/DISLOC ANT APPROACH INCL PLACE INT FI     N     3
                      22318    8                      OPEN TX/REDUC ODONTOID FRAC/DISLOC ANT APPROACH INCL PLACE INT FI     N     3
                      22319    2                      OPEN TX/REDUC ODONTOID FRAC/DISLOC ANT APPROACH INCL INT FIX W/GR     N     3
                      22319    7                      OPEN TX/REDUC ODONTOID FRAC/DISLOC ANT APPROACH INCL INT FIX W/GR     N     3
                      22319    8                      OPEN TX/REDUC ODONTOID FRAC/DISLOC ANT APPROACH INCL INT FIX W/GR     N     3
                      22325    2                      OPEN TRTMNT OF VRTRBRL FRACT/DISLOC, POST APPRCH, 1 VERT/SGMNT        N     3
                      22325    7                      OPEN TREATMENT OF VERTEBRAL BODY FRACTURE AND/OR                      N     3
                      22325    8                      OPEN TREATMENT OF VERTEBRAL BODY FRACTURE AND/OR                      N     3
                      22326    2                      OPEN TRTMNT OF VRTRBRL FRACT/DISLOC,POST APPRCH, 1 VRT/SGMT THORA     N     3
                      22326    7                      OPEN TREATMENT OF VERTEBRAL BODY FRACTURE AND/OR                      N     3
                      22326    8                      OPEN TREATMENT OF VERTEBRAL BODY FRACTURE AND/OR                      N     3
                      22327    2                      OPEN TRTMNT OF VERT FRACT/DISLOC, POST APPRCH 1 VRT/SGMT CERVICAL     N     3
                      22327    7                      OPEN TREATMENT OF VERTEBRAL BODY FRACTURE AND/OR                      N     3
                      22328    2                      OPEN TREATMENT OF VERTEBRAL FRACTURES; EA. ADD'L FRACTURED VERTBR     N     3
                      22328    8                      OPEN TREATMENT OF VERTEBRAL FRACTURES; EA. ADD'L FRACTURED VERTEB     N     3
                      22330    7                      OPEN TREATMENT AND FUSION, CERVICAL SPINE; POSTERI                    N     3
                      22330    8                      OPEN TREATMENT AND FUSION, CERVICAL SPINE; POSTERI                    N     3




Updated: 09/22/2006                                                                                                                    Page: 41 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      22335    7                      OPEN TREATMENT AND FUSION, CERVICAL SPINE; POSTERI                    N     3
                      22335    8                      OPEN TREATMENT AND FUSION, CERVICAL SPINE; POSTERI                    N     3
                      22345    7                      OPEN TREATMENT AND FUSION, CERVICAL SPINE; ANTERIO                    N     3
                      22345    8                      OPEN TREATMENT AND FUSION, CERVICAL SPINE; ANTERIO                    N     3
                      22355    7                      OPEN TREATMENT AND FUSION, POSTERIOR,WITH LOCAL BO                    N     3
                      22355    8                      OPEN TREATMENT AND FUSION, POSTERIOR,WITH LOCAL BO                    N     3
                      22356    7                      OPEN TREATMENT AND FUSION, POSTERIOR,WITH LOCAL BO                    N     3
                      22360    7                      OPEN TREATMENT & FUSION,POSTERIOR,WITH ILIAC OR OT                    N     3
                      22360    8                      OPEN TREATMENT & FUSION,POSTERIOR,WITH ILIAC OR OT                    N     3
                      22361    7                      OPEN TREATMENT & FUSION,POSTERIOR WITH ILIAC OR OT                    N     3
                      22361    8                      OPEN TREATMENT & FUSION,POSTERIOR WITH ILIAC OR OT                    N     3
                      22370    7                      OPEN TREATMENT & FUSION,POSTEROLATERAL OR ANTEROLA                    N     3
                      22371    7                      OPEN TREATMENT & FUSION,POSTEROLATERAL OR ANTEROLA                    N     3
                      22379    7                      HARRINGTON ROD TECHNIQUE                                              N     3
                      22505    2                      MANIPULATION OF SPINE REQUIRING ANESTHESIA, ANY RE                    N     3
                      22505    7                      MANIPULATION OF SPINE REQUIRING ANESTHESIA, ANY RE                    N     3
                      22505    F                      MANIPULATION OF SPINE REQUIRING ANESTHESIA, ANY RE                    N     3
                      22520    2                      PERCUT.VERTEBRO.ONE VERTEB.BODY UNILATERAL OR BILAT.INJ.THORACIC      N     3
                      22521    2                      PERCUT.VERTEB.ONE VERTEB.BODY UNILAT.OR BILAT.INJ.LUMB.               N     3
                      22522    2                      PERCUT.VERTEB.ONE VERTEB.BODY UNILAT.OR BILAT.INJECTION               N     3
                      22523    2                      PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUTING CAVITY CERATION (F     N     3
                      22523    7                      PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUTING CAVITY CERATION (F     N     3
                      22523    8                      PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUTING CAVITY CERATION (F     N     3
                      22524    2                      PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (F     N     3
                      22524    7                      PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (F     N     3
                      22524    8                      PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (F     N     3
                      22525    2                      PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (F     N     3
                      22525    7                      PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (F     N     3
                      22525    8                      PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (F     N     3
                      22532    2                      ARTHRODESIS LATERAL EXTRACAVITARY TECHNIQUE INCLUDING MINI            N     3
                      22533    2                      ARTHRODESIS LATERAL EXTRACAVITARY TECHNIQUE                           N     3
                      22534    2                      ARTHRODESIS, LATERAL EXTRACAVITARY TECHNIQUE INCLUDING MINIMAL DI     N     3
                      22546    8                      OPEN TREATMENT OF HUMERAL SUPRACONDYLAR WITH INTERCONDYLAR EXTENS     N     3
                      22548    2                      ARTHRDS, ANTR TRNSRL/EXTRLRL TECH, CLIVUS C1-C2 W/-W/O EXCISION       N     3
                      22548    7                      ARTHRDSIS ANT TROR OR XTRORL C1-C2 W BN GFT W WO O                    N     3
                      22548    8                      ARTHRDSIS ANT TROR OR XTRORL C1-C2 W BN GFT W WO O                    N     3
                      22550    7                      ARTHRODESIS WITH DISKECTOMY, CERVICAL,POSTERIOR;LO                    N     3
                      22550    8                      ARTHRODESIS WITH DISKECTOMY, CERVICAL,POSTERIOR;LO                    N     3
                      22552    7                      ARTHRODESIS WITH DISKECTOMY, CERVICAL,POSTERIOR;WI                    N     3
                      22552    8                      ARTHRODESIS WITH DISKECTOMY, CERVICAL,POSTERIOR,WI                    N     3
                      22554    2                      ARTHRDS,ANTER INTRBDY TECH, MIN DSKCTMY TO PREP INTRSPC, CERVICAL     N     3
                      22554    7                      ARTRODIS ANT BODY TECH CERV BLOW C-2 W BNE GRAFT                      N     3
                      22554    8                      ARTRODIS ANT BODY TECH CERV BLOW C-2 W BNE GRAFT                      N     3
                      22555    7                      ARTHRODESIS WITH DISKECTOMY, CERVICAL, ANTERIOR,WI                    N     3
                      22555    8                      ARTHRODESIS WITH DISKECTOMY, CERVICAL, ANTERIOR,WI                    N     3
                      22556    2                      ARTHRDSIS,ANTER INTER TECH, MIN DISKCTMY TO PREP INTRSPC, THRACIC     N     3
                      22556    7                      ARTHRODESIS, THORACIC, WITH LOCAL BONE RIB                            N     3




Updated: 09/22/2006                                                                                                                    Page: 42 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      22558    2                      ARTHRDES, ANT INTER TECH,MIN DSKCTMY TO PREP INTRSPC, LUMBAR          N     3
                      22558    7                      ARTHRODESIS, LUMBAR, WITH BONE GRAFT                                  N     3
                      22558    8                      ARTHRODESIS, LUMBAR WITH BONE GRAFT                                   N     3
                      22560    7                      ARTHRODESIS WITH DISKECTOMY, LUMBAR OR THORACIC,PO                    N     3
                      22560    8                      ARTHRODESIS WITH DISKECTOMY, LUMBAR OR THORACIC,PO                    N     3
                      22561    7                      ARTHRODESIS WITH DISKECTOMY, LUMBAR OR THORACIC;WI                    N     3
                      22561    8                      ARTHRODESIS WITH DISKECTOMY, LUMBAR OR THORACIC;WI                    N     3
                      22565    7                      ARTHRODESIS WITH DISKECTOMY, LOWER LUMBAR SPINE, A                    N     3
                      22565    8                      ARTHRODESIS WITH DISKECTOMY, LOWER LUMBAR SPINE, A                    N     3
                      22585    2                      ARTHRDES, ANT INTER TECH, MIN DSKCTMY TO PREP INTRSPC, EA INTRSPC     N     3
                      22585    7                      ARTHRODESIS EACH ADDT'L INTRSPACE IN ADD TO SNG LE                    N     3
                      22585    8                      ARTHRODESIS EA ADDT'L INTRSPACE IN ADD TO SNGLE LE                    N     3
                      22590    2                      ARTHRDSIS, POST TECHNIQUE, CRANIOCERVICAL (OCCIPUT C-2_)              N     3
                      22590    7                      ARTHRDSIS POST TEC CRNOCRVCL OCC-C2 W BNE GRFT FIX                    N     3
                      22590    8                      ARTHRDSIS POST TEC CRNOCRVCL OCC - C2 W BN GFT FIX                    N     3
                      22595    2                      ARTHODESIS, POSTERIOR TECHNIQUE, ATLAS-AXIS (C1-C2)                   N     3
                      22595    7                      ARTHORDESIS POST TECH ATLASAXIS W/BONE GRAFT                          N     3
                      22595    8                      ARTHRODESIS,POSTERIOR TECHNIQUE, CRANIOCERVICAL (OCCIPUT-C-2)         N     3
                      22600    2                      ARTHDSIS, POSTERIOR/OLATERAL TECH, 1 LEVEL, CERVICAL BELOW C2 SEG     N     3
                      22600    7                      CERVICAL FUSION, POSTERIOR APPROACH, BELOW C1 LEVE                    N     3
                      22600    8                      CERVICAL FUSION, POSTERIOR APPROACH, BELOW C1 LEVE                    N     3
                      22605    2                      CERVICAL FUSION, POSTERIOR APPROACH, BELOW C1 LEVE                    N     3
                      22605    7                      CERVICAL FUSION, POSTERIOR APPROACH, BELOW C1 LEVE                    N     3
                      22605    8                      CERVICAL FUSION, POSTERIOR APPROACH, BELOW C1 LEVE                    N     3
                      22610    2                      ARTHODES, POSTERIOR/OLATERAL TECH, 1 LEVEL THORACIC                   N     3
                      22610    7                      ARTHRODESIS,POST TECHNQ,W/LOCAL BONE ALLOGRFT;THOR                    N     3
                      22612    2                      ARTHODES, POSTERIOR/OLATERAL TECH, 1 LEVEL, LUMBAR                    N     3
                      22612    7                      ARTHRODESIS LUMBAR SPINE                                              N     3
                      22612    8                      ARTRDSIS POST POSTLAT TECH W BNE GRFT FIXAT LUMBAR                    N     3
                      22614    2                      ARTHRODESIS; SINGLE LEVEL; EA. ADDL VERTEBRAL SEGMENT                 N     3
                      22614    8                      ARTHRODESIS; SINGLE LEVEL; EA. ADD'L VERTEBRAL SEGMENT                N     3
                      22615    7                      CERVICAL FUSION, ANTERIOR APPROACH (C3-T1) WITH IL                    N     3
                      22615    8                      CERVICAL FUSION, ANTERIOR APPROACH (C3-T1) WITH IL                    N     3
                      22617    2                      ATLAS-AXIS FUSION (C1-C2 OR C3) WITH ILIAC OR OTHE                    N     3
                      22617    7                      ATLAS-AXIS FUSION (C1-C2 OR C3) WITH ILIAC OR OTHE                    N     3
                      22617    8                      ATLAS-AXIS FUSION (C1-C2 OR C3) WITH ILIAC OR OTHE                    N     3
                      22620    2                      CERVICOCRANIAL FUSION (OCCIPUT THROUGH C2) WITH IL                    N     3
                      22620    7                      CERVICOCRANIAL FUSION (OCCIPUT THROUGH C2) WITH IL                    N     3
                      22625    7                      ARTHORDESIS,POSTERIOR,POST OR LAT TRANS PROC TECH                     N     3
                      22630    2                      ARTHODESIS, POSTERIOR INTERBODY TECHNIQUE, 1 INTERSPACE, LUMBAR       N     3
                      22630    7                      ARTRODIS POST INT TECH W BONE OR INT FIX LUMBAR                       N     3
                      22630    8                      ARTRODIS POST INT TECH W BONE OR INT FIX LUMBAR                       N     3
                      22632    2                      ARTHRODESIS; EA. ADD'L INTERSPACE                                     N     3
                      22632    8                      ARTHRODESIS; EA. ADD'L INTERSPACE                                     N     3
                      22640    7                      THORACIC OR LUMBAR FUSION, POSTERIOR OR POSTEROLAT                    N     3
                      22640    8                      THORACIC OR LUMBAR FUSION, POSTERIOR OR POSTEROLAT                    N     3
                      22645    7                      THORACIC OR LUMBAR FUSION, POSTERIOR OR POSTEROLAT                    N     3




Updated: 09/22/2006                                                                                                                    Page: 43 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      22645    8                      THORACIC OR LUMBAR FUSION, POSTERIOR OR POSTEROLAT                    N     3
                      22655    7                      THORACIC OR LUMBAR FUSION;POSTERIOR,WITH ILIAC OR                     N     3
                      22655    8                      THORACIC OR LUMBAR FUSION;POSTERIOR,WITH ILIAC OR                     N     3
                      22670    7                      THORACIC OR LUMBAR FUSION;LATERAL,WITH ILIAC OR OT                    N     3
                      22670    8                      THORACIC OR LUMBAR FUSION;LATERAL,WITH ILIAC OR OT                    N     3
                      22680    7                      THORACIC OR LUMBAR FUSION;ANTEROLATERAL OR ANTERIO                    N     3
                      22680    8                      THORACIC OR LUMBAR FUSION;ANTEROLATERAL OR ANTERIO                    N     3
                      22700    7                      LUMBAR SPINE FUSION; ANTERIOR INTERBODY FUSION                        N     3
                      22700    8                      LUMBAR SPINE FUSION; ANTERIOR INTERBODY FUSION                        N     3
                      22720    7                      LUMBAR SPINE FUSION; POSTERIOR, HARRINGTON OR KNOD                    N     3
                      22720    8                      LUMBAR SPINE FUSION; POSTERIOR, HARRINGTON OR KNOD                    N     3
                      22730    7                      ARTHRODESIS, PRIMARY OR REPAIR OF PSEUDARTHROSIS;                     N     3
                      22730    8                      ARTHRODESIS, PRIMARY OR REPAIR OF PSEUDARTHROSIS;                     N     3
                      22735    7                      ARTHRODESIS, PRIMARY OR REPAIR OF PSEUDARTHROSIS;                     N     3
                      22800    2                      ARTHRDES, POST FOR SPINE DEFORM, W/-W/O CAST,UP TO 6 VERT SEGMENT     N     3
                      22800    7                      ARTHRODESIS,PRIMARY FOR SCOLIOSIS(W-W/O POSTOP CAS                    N     3
                      22800    8                      ARTHRODESIS,PRIMARY FOR SCOLIOSIS(W-W/O POSTOP CAS                    N     3
                      22801    7                      ARTHRODESIS, PRIMARY FOR SCOLIOSIS, 6 OR LESS VERT                    N     3
                      22801    8                      ARTHRODESIS, PRIMARY FOR SCOLIOSIS, 6 OR LESS VERT                    N     3
                      22802    2                      ARTHODESIS, POSTERIOR FOR SPINE DEFORM, 2/-W/O CAST,4-7 SEGMENTS      N     3
                      22802    7                      ARTHRODESIS,PRIMARY FOR SCOLIOSIS(W-W/O POSTOP CAS                    N     3
                      22802    8                      ARTHRODESIS,PRIMARY FOR SCOLIOSIS(W-W/O POSTOP CAS                    N     3
                      22803    7                      ARTHRODESIS, PRIMARY FOR SCOLIOSIS, 7 OR MORE VERT                    N     3
                      22804    2                      ARTHRODESIS; 13 OR MORE VERTEBRAL SEGMENTS                            N     3
                      22804    7                      ARTHRODESIS; 13 OR MORE VERTEBRAL SEGMENTS                            N     3
                      22804    8                      ARTHRODESIS; 13 OR MORE VERTEBRAL SEGMENTS                            N     3
                      22808    2                      ARTHRODESIS; ANTERIOR; 2 TO 3 VERTEBRAL SEGMENTS                      N     3
                      22808    7                      ANESTHESIA, ARTHRODESIS;ANTERIOR;2TO3 VERTEBRAL SEGMENTS              N     3
                      22808    8                      ARTHRODESIS; ANTERIOR; 2 TO 3 VERTEBRAL SEGMENTS                      N     3
                      22810    2                      ARTHRODESIS ANT/SPINE DEFORM W/WO CAST 4-7 VERT                       N     3
                      22810    7                      ARTHRODESIS ANT/SPINE DEFORM W/WO CAST 4-7 VERT                       N     3
                      22810    8                      ARTHRODESIS ANT/SPINE DEFORM W/WO CAST 4-7 VERT                       N     3
                      22812    2                      ARTHRODES, ANTERIOR, SPINE DEFORM, W/-W/O CAST, 8+ VERT SEGMENTS      N     3
                      22812    7                      ARTRODS FOR SP DEF ANT W WO CAST GRAFT 8 OR MOR VR                    N     3
                      22812    8                      ARTRODS FOR SP DEF ANT W WO CAST GRAFT 8 OR MOR VR                    N     3
                      22818    2                      KYPECTOMY,CIRCUMF.EXPOS.SPINE&RESEC.VERTEBRAL SEG. 1 OR 2 SEGMENT     N     3
                      22818    7                      KYPHECTOMY,CIRCUM.EXPOSURE OF SPINE/RESEC.VERTEBRAL SEG.1OR2 SEGM     N     3
                      22818    8                      KYPHECTOMY,CIRCUM.EXPOS. SPINE&RESEC.VERTREBRAL SEG. 1 OR 2 SEGME     N     3
                      22819    2                      KYPHECTOMY,CIRCUM.EXPOS.SPINE&RESEC.VERTEBRAL SEG.3 OR MORE           N     3
                      22819    7                      KYPHECTOMY,CIRCUM.EXPOS.SPINE&RESEC.VERTEBRAL SEGMENTS 3OR MORE       N     3
                      22819    8                      KYPHECTOMY,CIRCUM.EXPOS.SPINE&RESEC.VERTEBRAL SEGMENTS 3 OR MORE      N     3
                      22830    2                      EXPLORATION OF SPINAL FUSION                                          N     3
                      22830    7                      EXPLORATION OF SPINAL FUSION                                          N     3
                      22830    8                      EXPLORATION OF SPINAL FUSION                                          N     3
                      22840    2                      POSTERIOR NON SEGMENT INSTRMNTAT.(1 HARRINGTON ROD TECHNIQUE)         N     3
                      22840    7                      POSTERIOR INSTRUMENTATION; (EG,HARRINGTON ROD TECH                    N     3
                      22840    8                      POSTERIOR INSTRUMENTATION; (EG,HARRINGTON ROD TECH                    N     3




Updated: 09/22/2006                                                                                                                    Page: 44 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      22841    2                      INTERNAL SPINAL FIXATION BY WIRING OF SPINOUS PROCESSES               N     3
                      22841    8                      INTERNAL SPINAL FIXATION BY WIRING OF SPINOUS PROCESSES               N     3
                      22842    2                      PEDICLE FIXATION, 2 RODS W/MULT HOOK&SUBLAM WIRE,3-6 VERT SEGMENT     N     3
                      22842    7                      POSTERIOR INSTMNTATION SE6 WIRING E6 LUQUE TECHN                      N     3
                      22842    8                      SEGMENTAL WIRING EG LUQUETECH LIST SPTLY                              N     3
                      22843    2                      PSOTERIOR SEGMENTAL INSTRUMENTATION 3-6 VERTEBRAL SEGMENTS            N     3
                      22843    8                      POSTERIOR SEGMENTAL INSTRUMENTATION 3-6 VERTEBRAL SEGMENTS            N     3
                      22844    2                      POSTERIOR SEGMENTAL INSTRUMENTATION 13 OR MORE VERTEBRAL SEGMENTS     N     3
                      22844    8                      POSTERIOR SEGMENTAL INSTRUMENTATION - 13+ VERTEBRAL SEGMENTS          N     3
                      22845    2                      ANTERIOR INSTRUMENTATION; 3 VERTEBRAL SEGMENTS                        N     3
                      22845    7                      ANTERIOR INSTRUMENTATION; (EG, DWYER INSTRUMENTATI                    N     3
                      22845    8                      ANTERIOR INSTRUMENTATION; 2 TO 3 VERTEBRAL SEGMENTS                   N     3
                      22846    2                      ANTERIOR INSTRUMENTATION; 4-7 VERTEBRAL SEGMENTS                      N     3
                      22846    8                      ANTERIOR INSTRUMENTATION; 4-7 VERTEBRAL SEGMENTS                      N     3
                      22847    2                      ANTERIOR INSTRUMENTATION; 8 OR MORE VERTEBRAL SEGMENTS                N     3
                      22847    8                      ANTERIOR INSTRUMENTATION; 8 OR MORE VERTEBRAL SEGMENTS                N     3
                      22848    2                      PELVIC FIXATION OTHER THAN SACRUM                                     N     3
                      22848    8                      PELVIC FIXATION OTHER THAN SACRUM                                     N     3
                      22849    2                      REINSERTION OF SPINAL FIXATION DEVICE                                 N     3
                      22849    7                      REINSERTION OF SPINAL FIXATION DEVICE                                 N     3
                      22849    8                      REINSERTION OF SPINAL FIXATION DEVICE                                 N     3
                      22850    2                      REMOVAL OF POSTERIOR INSTRUMENTATION (EG, HARRINGT                    N     3
                      22850    7                      REMOVAL OF POSTERIOR INSTRUMENTATION (EG, HARRINGT                    N     3
                      22850    8                      REMOVAL OF POSTERIOR INSTRUMENTATION (EG, HARRINGT                    N     3
                      22851    2                      APPLICATION OF PROSTHETIC DEVICE TO VERTEBRAL DEFECT OR INTERSPAC     N     3
                      22851    8                      APPLICATION OF PROSTHETIC DEVICE TO VERTEBRAL DEFECT OR INTERSPAC     N     3
                      22852    2                      RMVL POST SEG INSTRUMENTATION                                         N     3
                      22852    7                      RMVL POST SEG INSTRUMENTATION                                         N     3
                      22852    8                      RMVL POST SEG INSTRUMENTATION                                         N     3
                      22855    2                      REMOVAL OF ANTERIOR INSTRUMENTATION (EG, DWYER DEV                    N     3
                      22855    7                      REMOVAL OF ANTERIOR INSTRUMENTATION (EG, DWYER DEV                    N     3
                      22855    8                      REMOVAL OF ANTERIOR INSTRUMENTATION (EG, DWYER DEV                    N     3
                      22899    7                      UNLISTED PROCEDURE, SPINE                                             N     3
                      22900    2                      EXCISION, ABDOMINAL WALL TUMOR, SUBFASCIAL                            N     3
                      22900    7                      EXCISION, ABDOMINAL WALL TUMOR, SUBFASCIAL                            N     3
                      22900    8                      EXCISION, ABDOMINAL WALL TUMOR, SUBFASCIAL                            N     3
                      22900    F                      EXCISION, ABDOMINAL WALL TUMOR, SUBFASCIAL                            N     3
                      22910    2                      ABDOMINAL FASCIAL TRANSPLANTS, BILATERAL                              N     3
                      22910    7                      ABDOMINAL FASCIAL TRANSPLANTS, BILATERAL                              N     3
                      22910    8                      ABDOMINAL FASCIAL TRANSPLANTS, BILATERAL                              N     3
                      22999    7                      UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTE                    N     3
                      23000    2                      REMOVAL OF SUBDELTOID (OR INTRATENDINOUS) CALCAREOUS DEPOSITS         N     3
                      23000    7                      REMOVAL OF SUBDELTOID (OR INTRATENDINOUS) CALCAREO                    N     3
                      23000    F                      REMOVAL OF SUBDELTOID (OR INTRATENDINOUS) CALCAREOUS DEPOSITS         N     3
                      23020    2                      CAPSULAR CONTRACTURE RELEASE (SEVER TYPE) FOR ERB'                    N     3
                      23020    7                      CAPSULAR CONTRACTURE RELEASE (SEVER TYPE) FOR ERB'                    N     3
                      23020    8                      CAPSULAR CONTRACTURE RELEASE (SEVER TYPE) FOR ERB'                    N     3




Updated: 09/22/2006                                                                                                                    Page: 45 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      23020    F                      CAPSULAR CONTRACTURE RELEASE (SEVER TYPE) FOR ERB'                    N     3
                      23030    7                      INCISION AND DRAINAGE; DEEP ABSCESS OR HEMATOMA                       N     3
                      23030    F                      INCISION AND DRAINAGE; DEEP ABSCESS OR HEMATOMA                       N     3
                      23031    2                      INCISION AND DRAINAGE; INFECTED BURSA                                 N     3
                      23031    7                      INCISION AND DRAINAGE; INFECTED BURSA                                 N     3
                      23031    F                      INCISION AND DRAINAGE; INFECTED BURSA                                 N     3
                      23035    2                      INCISION,BONE CORTEX (EG SEVER TYPE PROCEDURE                         N     3
                      23035    7                      INCISION, DEEP, WITH OPENING OF CORTEX FOR OSTEOMY                    N     3
                      23035    F                      INCISION,BONE CORTEX (EG SEVER TYPE PROCEDURE                         N     3
                      23036    2                      INCISION, DEEP, WITH OPENING OF CORTEX FOR OSTEOMY                    N     3
                      23036    7                      INCISION, DEEP, WITH OPENING OF CORTEX FOR OSTEOMY                    N     3
                      23040    2                      ARTHROTOMY GLENOHUMERAL JOINT, INCLUDING EXPLORATION, DRAINAGE OR     N     3
                      23040    7                      ARTHROTOMY WITH EXPLORATION, DRAINAGE OR REMOVAL O                    N     3
                      23040    8                      ARTHROTOMY WITH EXPLORATION, DRAINAGE OR REMOVAL O                    N     3
                      23040    F                      ARTHROTOMY GLENOHUMERAL JOINT, INCLUDING EXPLORATION, DRAINAGE OR     N     3
                      23042    2                      ARTHROTOMY WITH EXPLORATION, DRAINAGE OR REMOVAL O                    N     3
                      23042    7                      ARTHROTOMY WITH EXPLORATION, DRAINAGE OR REMOVAL O                    N     3
                      23044    2                      ARTHROTOMY WITH EXPLORATION, DRAINAGE OR REMOVAL OF FOREIGN BODY      N     3
                      23044    7                      ARTHROTOMY WITH EXPLORATION, DRAINAGE OR REMOVAL O                    N     3
                      23044    F                      ARTHROTOMY WITH EXPLORATION, DRAINAGE OR REMOVAL OF FOREIGN BODY      N     3
                      23065    2                      BIOPSY, SOFT TISSUES; SUPERFICIAL                                     N     3
                      23066    2                      BIOPSY, SOFT TISSUES; DEEP                                            N     3
                      23066    F                      BIOPSY, SOFT TISSUES; DEEP                                            N     3
                      23075    2                      EXCISION,SOFT TISSUE TUMOR,SHOULDER AREA SUBCUTANEOUS                 N     3
                      23075    F                      EXCISION,SOFT TISSUE TUMOR,SHOULDER AREA SUBCUTANEOUS                 N     3
                      23076    2                      EXCISION, BENIGN TUMOR; DEEP, SUBFASCIAL OR INTRAM                    N     3
                      23076    7                      EXCISION, BENIGN TUMOR; DEEP, SUBFASCIAL OR INTRAM                    N     3
                      23076    F                      EXCISION, BENIGN TUMOR; DEEP, SUBFASCIAL OR INTRAM                    N     3
                      23077    2                      RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM                    N     3
                      23077    7                      RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM                    N     3
                      23077    F                      RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM                    N     3
                      23100    2                      ARTHROTOMY GLENOHUMERAL JOINT, INCLUDING BIOPSY                       N     3
                      23100    7                      ARTHROTOMY FOR BIOPSY, GLENOHUMERAL JOINT                             N     3
                      23100    F                      ARTHROTOMY GLENOHUMERAL JOINT, INCLUDING BIOPSY                       N     3
                      23101    2                      ARTHROTOMY ACROMIOCLAVICULAR JOINT OR STERNOCLAVICULAR JOINT          N     3
                      23101    7                      ARTHROTOMY FOR BIOPSY OR FOR EXCISION OF TORN CART                    N     3
                      23101    F                      ARTHROTOMY ACROMIOCLAVICULAR JOINT OR STERNOCLAVICULAR JOINT          N     3
                      23105    2                      ARTHROTOMY;GLENOHUMERAL JOINT, WITH SYNOVECTOMY,WITH OR W/OUT BIO     N     3
                      23105    7                      ARTHROTOMY FOR SYNOVECTOMY; GLENOHUMERAL JOINT                        N     3
                      23105    8                      ARTHROTOMY FOR SYNOVECTOMY; GLENOHUMERAL JOINT                        N     3
                      23105    F                      ARTHROTOMY;GLENOHUMERAL JOINT, WITH SYNOVECTOMY,WITH OR W/OUT BIO     N     3
                      23106    2                      ARTHROTOMY STERNOCLAVICULAR JOINT,WITH SYNOVECTOMY,W/WO BIOPSY        N     3
                      23106    7                      ARTHROTOMY FOR SYNOVECTOMY; ACROMIOCLAVICULAR, STE                    N     3
                      23106    F                      ARTHROTOMY STERNOCLAVICULAR JOINT,WITH SYNOVECTOMY,W/WO BIOPSY        N     3
                      23107    7                      ARTHROTOMY, GLENOHUMERAL JOINT, WITH JOINT EXPLORA                    N     3
                      23107    F                      ARTHROTOMY, GLENOHUMERAL JOINT, WITH JOINT EXPLORA                    N     3
                      23110    2                      EXCISION, SUBACROMIAL (SUBDELTOID) BURSA                              N     3




Updated: 09/22/2006                                                                                                                    Page: 46 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      23110    7                      EXCISION, SUBACROMIAL (SUBDELTOID) BURSA                              N     3
                      23120    2                      CLAVICULECTOMY; PARTIAL                                               N     3
                      23120    7                      CLAVICULECTOMY; PARTIAL                                               N     3
                      23120    8                      CLAVICULECTOMY; PARTIAL                                               N     3
                      23120    F                      CLAVICULECTOMY; PARTIAL                                               N     3
                      23125    2                      CLAVICULECTOMY; TOTAL                                                 N     3
                      23125    7                      CLAVICULECTOMY; TOTAL                                                 N     3
                      23125    8                      CLAVICULECTOMY; TOTAL                                                 N     3
                      23125    F                      CLAVICULECTOMY; TOTAL                                                 N     3
                      23130    2                      ACROMIOPLASTY OR ACROMIONECTOMY,PARTIAL,W/WO CORACOACROMIAL LIGAM     N     3
                      23130    7                      ACROMIONECTOMY, PARTIAL OR TOTAL                                      N     3
                      23130    8                      ACROMIONECTOMY, PARTIAL OR TOTAL                                      N     3
                      23130    F                      ACROMIOPLASTY OR ACROMIONECTOMY,PARTIAL,W/WO CORACOACROMIAL LIGAM     N     3
                      23140    2                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR                    N     3
                      23140    7                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR                    N     3
                      23140    F                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR                    N     3
                      23145    2                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR                    N     3
                      23145    7                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR                    N     3
                      23145    8                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR                    N     3
                      23145    F                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR                    N     3
                      23146    2                      EXCISION OR CURETTAGE OF BONE CYST;WITH HOMOGENOUS                    N     3
                      23146    7                      EXCISION OR CURETTAGE OF BONE CYST;WITH HOMOGENOUS                    N     3
                      23146    F                      EXCISION OR CURETTAGE OF BONE CYST;WITH HOMOGENOUS                    N     3
                      23150    2                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR                    N     3
                      23150    7                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR                    N     3
                      23150    8                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR                    N     3
                      23150    F                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR                    N     3
                      23155    2                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR                    N     3
                      23155    7                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR                    N     3
                      23155    F                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR                    N     3
                      23156    2                      EXCISION OR CURETTAGE OF BONE CYST;WITH HOMOGENOUS                    N     3
                      23156    7                      EXCISION OR CURETTAGE OF BONE CYST;WITH HOMOGENOUS                    N     3
                      23156    F                      EXCISION OR CURETTAGE OF BONE CYST;WITH HOMOGENOUS                    N     3
                      23170    2                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS,                     N     3
                      23170    7                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS,                     N     3
                      23170    F                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS,                     N     3
                      23171    2                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS,                     N     3
                      23171    7                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS,                     N     3
                      23172    2                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS,                     N     3
                      23172    7                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS,                     N     3
                      23172    F                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS,                     N     3
                      23173    2                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS,                     N     3
                      23173    7                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS,                     N     3
                      23174    2                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS,H                    N     3
                      23174    7                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS,H                    N     3
                      23174    F                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS,H                    N     3
                      23175    2                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS,H                    N     3




Updated: 09/22/2006                                                                                                                    Page: 47 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      23175    7                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS,H                    N     3
                      23180    2                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZATION OR DIAPHSE     N     3
                      23180    7                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA                    N     3
                      23180    8                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA                    N     3
                      23180    F                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZATION OR DIAPHSE     N     3
                      23181    2                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA                    N     3
                      23181    7                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA                    N     3
                      23182    2                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZATION OR DIAPHYS     N     3
                      23182    7                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA                    N     3
                      23182    F                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZATION OR DIAPHYS     N     3
                      23183    2                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA                    N     3
                      23183    7                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA                    N     3
                      23184    2                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA                    N     3
                      23184    7                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA                    N     3
                      23184    F                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA                    N     3
                      23185    2                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA                    N     3
                      23185    7                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA                    N     3
                      23190    2                      OSTECTOMY OF SCAPULA, PARTIAL                                         N     3
                      23190    7                      OSTECTOMY OF SCAPULA, PARTIAL                                         N     3
                      23190    F                      OSTECTOMY OF SCAPULA, PARTIAL                                         N     3
                      23195    2                      RESECTION HUMERAL HEAD                                                N     3
                      23195    7                      RESECTION HUMERAL HEAD                                                N     3
                      23195    F                      RESECTION HUMERAL HEAD                                                N     3
                      23200    2                      RADICAL RESECTION FOR TUMOR; CLAVICLE                                 N     3
                      23200    7                      RADICAL RESECTION FOR TUMOR; CLAVICLE                                 N     3
                      23210    2                      RADICAL RESECTION FOR TUMOR; SCAPULA                                  N     3
                      23210    7                      RADICAL RESECTION FOR TUMOR; SCAPULA                                  N     3
                      23220    2                      RADICAL RESECTION FOR TUMOR, PROXIMAL HUMERUS;                        N     3
                      23220    7                      RADICAL RESECTION FOR TUMOR, PROXIMAL HUMERUS;                        N     3
                      23221    2                      RADICAL RESECTION FOR TUMOR, PROXIMAL HUMERUS; WIT                    N     3
                      23221    7                      RADICAL RESECTION FOR TUMOR, PROXIMAL HUMERUS; WIT                    N     3
                      23222    2                      RADICAL RESECTION FOR TUMOR, PROXIMAL HUMERUS; WIT                    N     3
                      23222    7                      RADICAL RESECTION FOR TUMOR, PROXIMAL HUMERUS; WIT                    N     3
                      23330    2                      REMOVAL OF FOREIGN BODY; SUBCUTANEOUS                                 N     3
                      23330    F                      REMOVAL OF FOREIGN BODY; SUBCUTANEOUS                                 N     3
                      23331    2                      REMOVAL OF FOREIGN BODY; DEEP PROSTHETIC REMOVAL                      N     3
                      23331    7                      REMOVAL OF FOREIGN BODY; DEEP PROSTHETIC REMOVAL                      N     3
                      23331    8                      REMOVAL OF FOREIGN BODY; DEEP PROSTHETIC REMOVAL                      N     3
                      23331    F                      REMOVAL OF FOREIGN BODY; DEEP PROSTHETIC REMOVAL                      N     3
                      23332    2                      REMOVAL OF FOREIGN BODY; COMPLICATED, INCLUDING "T                    N     3
                      23332    7                      REMOVAL OF FOREIGN BODY; COMPLICATED, INCLUDING "T                    N     3
                      23350    2                      INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY                         N     3
                      23350    7                      INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY                         N     3
                      23395    2                      MUSCLE TRANSFER, ANY TYPE FOR PARALYSIS OF SHOULDE                    N     3
                      23395    7                      MUSCLE TRANSFER, ANY TYPE FOR PARALYSIS OF SHOULDE                    N     3
                      23395    F                      MUSCLE TRANSFER, ANY TYPE FOR PARALYSIS OF SHOULDE                    N     3
                      23397    2                      MUSCLE TRANSFER, ANY TYPE FOR PARALYSIS OF SHOULDE                    N     3




Updated: 09/22/2006                                                                                                                    Page: 48 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      23397    7                      MUSCLE TRANSFER, ANY TYPE FOR PARALYSIS OF SHOULDE     N     3
                      23397    F                      MUSCLE TRANSFER, ANY TYPE FOR PARALYSIS OF SHOULDE     N     3
                      23400    2                      SCAPULOPEXY                                            N     3
                      23400    7                      SCAPULOPEXY                                            N     3
                      23400    F                      SCAPULOPEXY                                            N     3
                      23405    2                      TENOMYOTOMY; SINGLE                                    N     3
                      23405    7                      TENOMYOTOMY; SINGLE                                    N     3
                      23405    F                      TENOMYOTOMY; SINGLE                                    N     3
                      23406    2                      TENOMYOTOMY; MULTIPLE THROUGH SAME INCISION            N     3
                      23406    7                      TENOMYOTOMY; MULTIPLE THROUGH SAME INCISION            N     3
                      23406    F                      TENOMYOTOMY; MULTIPLE THROUGH SAME INCISION            N     3
                      23410    2                      REPAIR OF RUPTURED SUPRASPINATUS TENDON OR MUSCULO     N     3
                      23410    7                      REPAIR OF RUPTURED SUPRASPINATUS TENDON OR MUSCULO     N     3
                      23410    8                      REPAIR OF RUPTURED SUPRASPINATUS TENDON OR MUSCULO     N     3
                      23410    F                      REPAIR OF RUPTURED SUPRASPINATUS TENDON OR MUSCULO     N     3
                      23412    2                      REPAIR OF RUPTURED SUPRASPINATUS TENDON OR MUSCULO     N     3
                      23412    7                      REPAIR OF RUPTURED SUPRASPINATUS TENDON OR MUSCULO     N     3
                      23412    8                      REPAIR OF RUPTURED SUPRASPINATUS TENDON OR MUSCULO     N     3
                      23412    F                      REPAIR OF RUPTURED SUPRASPINATUS TENDON OR MUSCULO     N     3
                      23415    2                      CORACOACROMIAL LIGAMENT RELEASE FOR CHRONIC RUPTUR     N     3
                      23415    7                      CORACOACROMIAL LIGAMENT RELEASE FOR CHRONIC RUPTUR     N     3
                      23415    8                      CORACOACROMIAL LIGAMENT RELEASE FOR CHRONIC RUPTUR     N     3
                      23415    F                      CORACOACROMIAL LIGAMENT RELEASE FOR CHRONIC RUPTUR     N     3
                      23420    2                      REPAIR OF COMPLETE SHOULDER CUFF AVULSION, CHRONIC     N     3
                      23420    7                      REPAIR OF COMPLETE SHOULDER CUFF AVULSION, CHRONIC     N     3
                      23420    8                      REPAIR OF COMPLETE SHOULDER CUFF AVULSION, CHRONIC     N     3
                      23420    F                      REPAIR OF COMPLETE SHOULDER CUFF AVULSION, CHRONIC     N     3
                      23430    2                      TENODESIS FOR RUPTURE OF LONG TENDON OF BICEPS         N     3
                      23430    7                      TENODESIS FOR RUPTURE OF LONG TENDON OF BICEPS         N     3
                      23430    8                      TENODESIS FOR RUPTURE OF LONG TENDON OF BICEPS         N     3
                      23430    F                      TENODESIS FOR RUPTURE OF LONG TENDON OF BICEPS         N     3
                      23440    2                      RESECTION OR TRANSPLANTATION OF LONG TENDON OF BIC     N     3
                      23440    7                      RESECTION OR TRANSPLANTATION OF LONG TENDON OF BIC     N     3
                      23440    F                      RESECTION OR TRANSPLANTATION OF LONG TENDON OF BIC     N     3
                      23450    2                      CAPSULORRHAPHY FOR RECURRENT DISLOCATION, ANTERIOR     N     3
                      23450    7                      CAPSULORRHAPHY FOR RECURRENT DISLOCATION, ANTERIOR     N     3
                      23450    8                      CAPSULORRHAPHY FOR RECURRENT DISLOCATION, ANTERIOR     N     3
                      23450    F                      CAPSULORRHAPHY FOR RECURRENT DISLOCATION, ANTERIOR     N     3
                      23455    2                      CAPSULORRHAPHY FOR RECURRENT DISLOCATION, ANTERIOR     N     3
                      23455    7                      CAPSULORRHAPHY FOR RECURRENT DISLOCATION, ANTERIOR     N     3
                      23455    8                      CAPSULORRHAPHY FOR RECURRENT DISLOCATION, ANTERIOR     N     3
                      23455    F                      CAPSULORRHAPHY FOR RECURRENT DISLOCATION, ANTERIOR     N     3
                      23460    2                      CAPSULORRHAPHY FOR RECURRENT DISLOCATION, ANTERIOR     N     3
                      23460    7                      CAPSULORRHAPHY FOR RECURRENT DISLOCATION, ANTERIOR     N     3
                      23460    8                      CAPSULORRHAPHY FOR RECURRENT DISLOCATION, ANTERIOR     N     3
                      23460    F                      CAPSULORRHAPHY FOR RECURRENT DISLOCATION, ANTERIOR     N     3
                      23462    2                      CAPSULORRHAPHY FOR RECURRENT DISLOCATION, ANTERIOR     N     3




Updated: 09/22/2006                                                                                                     Page: 49 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      23462    7                      CAPSULORRHAPHY FOR RECURRENT DISLOCATION, ANTERIOR     N     3
                      23462    F                      CAPSULORRHAPHY FOR RECURRENT DISLOCATION, ANTERIOR     N     3
                      23465    2                      CAPSULORRHAPHY FOR RECURRENT DISLOCATION, POSTERIO     N     3
                      23465    7                      CAPSULORRHAPHY FOR RECURRENT DISLOCATION, POSTERIO     N     3
                      23465    8                      CAPSULORRHAPHY FOR RECURRENT DISLOCATION, POSTERIO     N     3
                      23465    F                      CAPSULORRHAPHY FOR RECURRENT DISLOCATION, POSTERIO     N     3
                      23466    2                      CAPSULORRHAPHY FOR RECURRENT DISLOCATION WITH ANY      N     3
                      23466    7                      CAPSULORRHAPHY FOR RECURRENT DISLOCATION WITH ANY      N     3
                      23466    8                      CAPSULORRHAPHY FOR RECURRENT DISLOCATION WITH ANY      N     3
                      23466    F                      CAPSULORRHAPHY FOR RECURRENT DISLOCATION WITH ANY      N     3
                      23470    2                      ARTHROPLASTY WITH PROXIMAL HUMERAL IMPLANT             N     3
                      23470    7                      ARTHROPLASTY WITH PROXIMAL HUMERAL IMPLANT             N     3
                      23470    8                      ARTHROPLASTY WITH PROXIMAL HUMERAL IMPLANT             N     3
                      23472    2                      ARTHROPLASTY WITH GLENOID AND PROXIMAL HUMERAL REP     N     3
                      23472    7                      ARTHROPLASTY WITH GLENOID AND PROXIMAL HUMERAL REP     N     3
                      23472    8                      ARTHROPLASTY WITH GLENOID AND PROXIMAL HUMERAL REP     N     3
                      23480    2                      OSTEOTOMY, CLAVICLE, WITH OR WITHOUT INTERNAL FIXA     N     3
                      23480    7                      OSTEOTOMY, CLAVICLE, WITH OR WITHOUT INTERNAL FIXA     N     3
                      23480    8                      OSTEOTOMY, CLAVICLE, WITH OR WITHOUT INTERNAL FIXA     N     3
                      23480    F                      OSTEOTOMY, CLAVICLE, WITH OR WITHOUT INTERNAL FIXA     N     3
                      23485    2                      OSTEOTOMY, CLAVICLE, WITH OR WITHOUT INTERNAL FIXA     N     3
                      23485    7                      OSTEOTOMY, CLAVICLE, WITH OR WITHOUT INTERNAL FIXA     N     3
                      23485    8                      OSTEOTOMY, CLAVICLE, WITH OR WITHOUT INTERNAL FIXA     N     3
                      23485    F                      OSTEOTOMY, CLAVICLE, WITH OR WITHOUT INTERNAL FIXA     N     3
                      23490    7                      PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING      N     3
                      23490    F                      PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING      N     3
                      23491    7                      PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING      N     3
                      23491    F                      PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING      N     3
                      23500    2                      TREATMENT OF CLOSED CLAVICULAR FRACTURE; WITHOUT M     N     3
                      23500    7                      TREATMENT OF CLOSED CLAVICULAR FRACTURE; WITHOUT M     N     3
                      23500    F                      TREATMENT OF CLOSED CLAVICULAR FRACTURE; WITHOUT M     N     3
                      23505    2                      TREATMENT OF CLOSED CLAVICULAR FRACTURE;WITH MANIP     N     3
                      23505    7                      TREATMENT OF CLOSED CLAVICULAR FRACTURE;WITH MANIP     N     3
                      23505    F                      TREATMENT OF CLOSED CLAVICULAR FRACTURE;WITH MANIP     N     3
                      23515    2                      OPEN TREATMENT OF CLOSED OR OPEN CLAVICULAR WITH O     N     3
                      23515    7                      OPEN TREATMENT OF CLOSED OR OPEN CLAVICULAR WITH O     N     3
                      23515    8                      OPEN TREATMENT OF CLOSED OR OPEN CLAVICULAR WITH O     N     3
                      23515    F                      OPEN TREATMENT OF CLOSED OR OPEN CLAVICULAR WITH O     N     3
                      23520    2                      TREATMENT OF CLOSED STERNOCLAVICULAR DISLOCATION;      N     3
                      23520    7                      TREATMENT OF CLOSED STERNOCLAVICULAR DISLOCATION;      N     3
                      23520    F                      TREATMENT OF CLOSED STERNOCLAVICULAR DISLOCATION;      N     3
                      23525    2                      TREATMENT OF CLOSED STERNOCLAVICULAR DISLOCATION;      N     3
                      23525    7                      TREATMENT OF CLOSED STERNOCLAVICULAR DISLOCATION;      N     3
                      23525    F                      TREATMENT OF CLOSED STERNOCLAVICULAR DISLOCATION;      N     3
                      23530    2                      OPEN TREATMENT OF CLOSED OR OPEN STERNOCLAVICULAR      N     3
                      23530    7                      OPEN TREATMENT OF CLOSED OR OPEN STERNOCLAVICULAR      N     3
                      23530    F                      OPEN TREATMENT OF CLOSED OR OPEN STERNOCLAVICULAR      N     3




Updated: 09/22/2006                                                                                                     Page: 50 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      23532    2                      OPEN TREATMENT OF CLOSED OR OPEN STERNOCLAVICULAR      N     3
                      23532    7                      OPEN TREATMENT OF CLOSED OR OPEN STERNOCLAVICULAR      N     3
                      23532    F                      OPEN TREATMENT OF CLOSED OR OPEN STERNOCLAVICULAR      N     3
                      23540    2                      TREATMENT OF CLOSED ACROMIOCLAVICULAR DISLOCATION;     N     3
                      23540    7                      TREATMENT OF CLOSED ACROMIOCLAVICULAR DISLOCATION;     N     3
                      23540    F                      TREATMENT OF CLOSED ACROMIOCLAVICULAR DISLOCATION;     N     3
                      23545    2                      TREATMENT OF CLOSED ACROMIOCLAVICULAR DISLOCATION;     N     3
                      23545    7                      TREATMENT OF CLOSED ACROMIOCLAVICULAR DISLOCATION;     N     3
                      23545    F                      TREATMENT OF CLOSED ACROMIOCLAVICULAR DISLOCATION;     N     3
                      23550    2                      OPEN TREATMENT OF CLOSED OR OPEN ACROMIOCLAVICULAR     N     3
                      23550    7                      OPEN TREATMENT OF CLOSED OR OPEN ACROMIOCLAVICULAR     N     3
                      23550    8                      OPEN TREATMENT OF CLOSED OR OPEN ACROMIOCLAVICULAR     N     3
                      23550    F                      OPEN TREATMENT OF CLOSED OR OPEN ACROMIOCLAVICULAR     N     3
                      23552    2                      OPEN TREATMENT OF CLOSED OR OPEN ACROMIOCLAVICULAR     N     3
                      23552    7                      OPEN TREATMENT OF CLOSED OR OPEN ACROMIOCLAVICULAR     N     3
                      23552    F                      OPEN TREATMENT OF CLOSED OR OPEN ACROMIOCLAVICULAR     N     3
                      23570    2                      TREATMENT OF CLOSED SCAPULAR FRACTURE; WITHOUT MAN     N     3
                      23570    7                      TREATMENT OF CLOSED SCAPULAR FRACTURE; WITHOUT MAN     N     3
                      23570    F                      TREATMENT OF CLOSED SCAPULAR FRACTURE; WITHOUT MAN     N     3
                      23575    2                      TREATMENT OF CLOSED SCAPULAR FRACTURE; WITH MANIPU     N     3
                      23575    7                      TREATMENT OF CLOSED SCAPULAR FRACTURE; WITH MANIPU     N     3
                      23575    F                      TREATMENT OF CLOSED SCAPULAR FRACTURE; WITH MANIPU     N     3
                      23585    2                      OPEN TREATMENT OF CLOSED OR OPEN SCAPULAR FRACTURE     N     3
                      23585    7                      OPEN TREATMENT OF CLOSED OR OPEN SCAPULAR FRACTURE     N     3
                      23585    8                      OPEN TREATMENT OF CLOSED OR OPEN SCAPULAR FRACTURE     N     3
                      23585    F                      OPEN TREATMENT OF CLOSED OR OPEN SCAPULAR FRACTURE     N     3
                      23600    2                      TREATMENT OF CLOSED HUMERAL (SURGICAL OR ANATOMICA     N     3
                      23600    7                      TREATMENT OF CLOSED HUMERAL (SURGICAL OR ANATOMICA     N     3
                      23600    F                      TREATMENT OF CLOSED HUMERAL (SURGICAL OR ANATOMICA     N     3
                      23605    2                      TREATMENT OF CLOSED HUMERAL (SURGICAL OR ANATOMICA     N     3
                      23605    7                      TREATMENT OF CLOSED HUMERAL (SURGICAL OR ANATOMICA     N     3
                      23605    F                      TREATMENT OF CLOSED HUMERAL (SURGICAL OR ANATOMICA     N     3
                      23615    2                      OPEN TREATMENT OF CLOSED OR OPEN HUMERAL FRACTURE,     N     3
                      23615    7                      OPEN TREATMENT OF CLOSED OR OPEN HUMERAL FRACTURE,     N     3
                      23615    8                      OPEN TREATMENT OF CLOSED OR OPEN HUMERAL FRACTURE,     N     3
                      23615    F                      OPEN TREATMENT OF CLOSED OR OPEN HUMERAL FRACTURE,     N     3
                      23616    2                      OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR AN     N     3
                      23616    7                      OPEN TRTMNT OF PROXIMAL HUMERAL (SURGICAL OR ANATO     N     3
                      23616    F                      OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR AN     N     3
                      23620    2                      TREATMENT OF CLOSED GREATER TUBEROSITY FRACTURE; W     N     3
                      23620    F                      TREATMENT OF CLOSED GREATER TUBEROSITY FRACTURE; W     N     3
                      23625    2                      TREATMENT OF CLOSED GREATER TUBEROSITY FRACTURE; W     N     3
                      23625    7                      TREATMENT OF CLOSED GREATER TUBEROSITY FRACTURE; W     N     3
                      23625    F                      TREATMENT OF CLOSED GREATER TUBEROSITY FRACTURE; W     N     3
                      23630    2                      OPEN TREAT OF CLOSED OR OPEN GREATER TUBEROSITY FR     N     3
                      23630    7                      OPEN TREAT OF CLOSED OR OPEN GREATER TUBEROSITY FR     N     3
                      23630    F                      OPEN TREAT OF CLOSED OR OPEN GREATER TUBEROSITY FR     N     3




Updated: 09/22/2006                                                                                                     Page: 51 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      23650    2                      TREATMENT OF CLOSED SHOULDER DISLOCATION, WITH MAN     N     3
                      23650    F                      TREATMENT OF CLOSED SHOULDER DISLOCATION, WITH MAN     N     3
                      23655    2                      TREATMENT OF CLOSED SHOULDER DISLOCATION, WITH MAN     N     3
                      23655    7                      TREATMENT OF CLOSED SHOULDER DISLOCATION, WITH MAN     N     3
                      23655    F                      TREATMENT OF CLOSED SHOULDER DISLOCATION, WITH MAN     N     3
                      23660    2                      OPEN TREATMENT OF CLOSED OR OPEN SHOULDER DISLOCAT     N     3
                      23660    7                      OPEN TREATMENT OF CLOSED OR OPEN SHOULDER DISLOCAT     N     3
                      23660    8                      OPEN TREATMENT OF CLOSED OR OPEN SHOULDER DISLOCAT     N     3
                      23660    F                      OPEN TREATMENT OF CLOSED OR OPEN SHOULDER DISLOCAT     N     3
                      23665    2                      TREATMENT OF CLOSED SHOULDER DISLOCATION, WITH FRA     N     3
                      23665    7                      TREATMENT OF CLOSED SHOULDER DISLOCATION, WITH FRA     N     3
                      23665    F                      TREATMENT OF CLOSED SHOULDER DISLOCATION, WITH FRA     N     3
                      23670    2                      OPEN TREATMENT OF CLOSED OR OPEN SHOULDER DISLOCAT     N     3
                      23670    7                      OPEN TREATMENT OF CLOSED OR OPEN SHOULDER DISLOCAT     N     3
                      23670    8                      OPEN TREATMENT OF CLOSED OR OPEN SHOULDER DISLOCAT     N     3
                      23670    F                      OPEN TREATMENT OF CLOSED OR OPEN SHOULDER DISLOCAT     N     3
                      23675    2                      TREATMENT OF CLOSED SHOULDER DISLOCATION, WITH SUR     N     3
                      23675    7                      TREATMENT OF CLOSED SHOULDER DISLOCATION, WITH SUR     N     3
                      23675    F                      TREATMENT OF CLOSED SHOULDER DISLOCATION, WITH SUR     N     3
                      23680    2                      OPEN TREATMENT OF CLOSED OR OPEN SHOULDER DISLOCAT     N     3
                      23680    7                      OPEN TREATMENT OF CLOSED OR OPEN SHOULDER DISLOCAT     N     3
                      23680    8                      OPEN TREATMENT OF CLOSED OR OPEN SHOULDER DISLOCAT     N     3
                      23680    F                      OPEN TREATMENT OF CLOSED OR OPEN SHOULDER DISLOCAT     N     3
                      23700    2                      MANIPULATION UNDER ANESTHESIA, INCLUDING APPLICATI     N     3
                      23700    7                      MANIPULATION UNDER ANESTHESIA, INCLUDING APPLICATI     N     3
                      23700    F                      MANIPULATION UNDER ANESTHESIA, INCLUDING APPLICATI     N     3
                      23800    2                      ARTHRODESIS, SHOULDER JOINT; WITH OR WITHOUT LOCAL     N     3
                      23800    7                      ARTHRODESIS, SHOULDER JOINT; WITH OR WITHOUT LOCAL     N     3
                      23800    8                      ARTHRODESIS, SHOULDER JOINT; WITH OR WITHOUT LOCAL     N     3
                      23800    F                      ARTHRODESIS, SHOULDER JOINT; WITH OR WITHOUT LOCAL     N     3
                      23802    2                      ARTHRODESIS, SHOULDER JOINT; WITH PRIMARY AUTOGENO     N     3
                      23802    7                      ARTHRODESIS, SHOULDER JOINT; WITH PRIMARY AUTOGENO     N     3
                      23802    F                      ARTHRODESIS, SHOULDER JOINT; WITH PRIMARY AUTOGENO     N     3
                      23900    2                      INTERTHORACOSCAPULAR AMPUTATION (FOREQUARTER)          N     3
                      23900    7                      INTERTHORACOSCAPULAR AMPUTATION (FOREQUARTER)          N     3
                      23900    8                      INTERTHORACOSCAPULAR AMPUTATION (FOREQUARTER)          N     3
                      23920    2                      DISARTICULATION OF SHOULDER;                           N     3
                      23920    7                      DISARTICULATION OF SHOULDER;                           N     3
                      23920    8                      DISARTICULATION OF SHOULDER;                           N     3
                      23921    2                      DISARTICULATION OF SHOULDER; SECONDARY CLOSURE OR      N     3
                      23921    7                      DISARTICULATION OF SHOULDER; SECONDARY CLOSURE OR      N     3
                      23921    F                      DISARTICULATION OF SHOULDER; SECONDARY CLOSURE OR      N     3
                      23929    7                      UNLISTED PROCEDURE, SHOULDER                           N     3
                      23930    2                      INCISION AND DRAINAGE; DEEP ABSCESS OR HEMATOMA        N     3
                      23930    7                      INCISION AND DRAINAGE; DEEP ABSCESS OR HEMATOMA        N     3
                      23930    F                      INCISION AND DRAINAGE; DEEP ABSCESS OR HEMATOMA        N     3
                      23931    2                      INCISION AND DRAINAGE; INFECTED BURSA                  N     3




Updated: 09/22/2006                                                                                                     Page: 52 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      23931    7                      INCISION AND DRAINAGE; INFECTED BURSA                  N     3
                      23931    F                      INCISION AND DRAINAGE; INFECTED BURSA                  N     3
                      23935    2                      INCISION, DEEP, WITH OPENING OF CORTEX FOR OSTEOMY     N     3
                      23935    7                      INCISION, DEEP, WITH OPENING OF CORTEX FOR OSTEOMY     N     3
                      23935    F                      INCISION, DEEP, WITH OPENING OF CORTEX FOR OSTEOMY     N     3
                      23936    2                      INCISION, DEEP, WITH OPENING OF CORTEX FOR OSTEOMY     N     3
                      23936    7                      INCISION, DEEP, WITH OPENING OF CORTEX FOR OSTEOMY     N     3
                      24000    2                      ARTHROTOMY, ELBOW, WITH EXPLORATION, DRAINAGE OR R     N     3
                      24000    7                      ARTHROTOMY, ELBOW, WITH EXPLORATION, DRAINAGE OR R     N     3
                      24000    8                      ARTHROTOMY, ELBOW, WITH EXPLORATION, DRAINAGE OR R     N     3
                      24000    F                      ARTHROTOMY, ELBOW, WITH EXPLORATION, DRAINAGE OR R     N     3
                      24001    2                      ARTHROTOMY,ELBOW,WITH EXPLORATION,DRAINAGE OR REMO     N     3
                      24001    7                      ARTHROTOMY,ELBOW,WITH EXPLORATION,DRAINAGE OR REMO     N     3
                      24006    2                      ARTHROTOMY OF THE ELBOW, WITH CAPSULAR EXCISION FO     N     3
                      24006    7                      ARTHROTOMY OF ELBOW WITH CAPSULAR EXICISN FOR CAPS     N     3
                      24065    2                      BIOPSY, SOFT TISSUES; SUPERFICIAL                      N     3
                      24065    7                      BIOPSY, SOFT TISSUES; SUPERFICIAL                      N     3
                      24066    2                      BIOPSY, SOFT TISSUES; DEEP                             N     3
                      24066    7                      BIOPSY, SOFT TISSUES; DEEP                             N     3
                      24066    F                      BIOPSY, SOFT TISSUES; DEEP                             N     3
                      24075    2                      EXCISION, BENIGN TUMOR; SUBCUTANEOUS                   N     3
                      24075    7                      EXCISION, BENIGN TUMOR; SUBCUTANEOUS                   N     3
                      24075    F                      EXCISION, BENIGN TUMOR; SUBCUTANEOUS                   N     3
                      24076    2                      EXCISION, BENIGN TUMOR; DEEP, SUBFASCIAL OR INTRAM     N     3
                      24076    7                      EXCISION, BENIGN TUMOR; DEEP, SUBFASCIAL OR INTRAM     N     3
                      24076    F                      EXCISION, BENIGN TUMOR; DEEP, SUBFASCIAL OR INTRAM     N     3
                      24077    7                      RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM     N     3
                      24077    F                      RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM     N     3
                      24100    2                      ARTHROTOMY, ELBOW; FOR SYNOVIAL BIOPSY ONLY            N     3
                      24100    7                      ARTHROTOMY, ELBOW; FOR SYNOVIAL BIOPSY ONLY            N     3
                      24100    F                      ARTHROTOMY, ELBOW; FOR SYNOVIAL BIOPSY ONLY            N     3
                      24101    2                      ARTHROTOMY, ELBOW;WITH JOINT EXPLO, WITH OR W/OUT      N     3
                      24101    7                      ARTHROTOMY, ELBOW;WITH JOINT EXPLO,WITH OR W/OUT B     N     3
                      24101    8                      ARTHROTOMY, ELBOW;WITH JOINT EXPLO,WITH OR W/OUT B     N     3
                      24101    F                      ARTHROTOMY, ELBOW;WITH JOINT EXPLO, WITH OR W/OUT      N     3
                      24102    2                      ARTHROTOMY, ELBOW; FOR SYNOVECTOMY                     N     3
                      24102    7                      ARTHROTOMY, ELBOW; FOR SYNOVECTOMY                     N     3
                      24102    8                      ARTHROTOMY, ELBOW; FOR SYNOVECTOMY                     N     3
                      24102    F                      ARTHROTOMY, ELBOW; FOR SYNOVECTOMY                     N     3
                      24105    2                      EXCISION, OLECRANON BURSA                              N     3
                      24105    7                      EXCISION, OLECRANON BURSA                              N     3
                      24105    F                      EXCISION, OLECRANON BURSA                              N     3
                      24110    2                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      24110    7                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      24110    8                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      24110    F                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      24115    2                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3




Updated: 09/22/2006                                                                                                     Page: 53 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      24115    7                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      24115    8                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      24115    F                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      24116    2                      EX OR CURETTAGE OF BONE CYST OR BENIGN TUMOR;WITH      N     3
                      24116    7                      EX OR CURETTAGE OF BONE CYST OR BENIGN TUMOR;WITH      N     3
                      24116    F                      EX OR CURETTAGE OF BONE CYST OR BENIGN TUMOR;WITH      N     3
                      24120    2                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      24120    7                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      24120    8                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      24120    F                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      24125    2                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      24125    7                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      24125    8                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      24125    F                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      24126    2                      EX OR CURETTAGE OF BONE CYST OR BENIGN TUMOR;WITH      N     3
                      24126    7                      EX OR CURETTAGE OF BONE CYST OR BENIGN TUMOR;WITH      N     3
                      24126    F                      EX OR CURETTAGE OF BONE CYST OR BENIGN TUMOR;WITH      N     3
                      24130    2                      EXCISION, RADIAL HEAD                                  N     3
                      24130    7                      EXCISION, RADIAL HEAD                                  N     3
                      24130    8                      EXCISION, RADIAL HEAD                                  N     3
                      24130    F                      EXCISION, RADIAL HEAD                                  N     3
                      24134    2                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS,      N     3
                      24134    7                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS,      N     3
                      24134    F                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS,      N     3
                      24135    2                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS;      N     3
                      24135    7                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS;      N     3
                      24136    2                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS,      N     3
                      24136    7                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS,      N     3
                      24136    F                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS,      N     3
                      24137    2                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS;      N     3
                      24137    7                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS;      N     3
                      24138    2                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS,      N     3
                      24138    7                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS,      N     3
                      24138    F                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS,      N     3
                      24139    2                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS;W     N     3
                      24139    7                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS;      N     3
                      24140    2                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3
                      24140    7                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3
                      24140    F                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3
                      24144    2                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3
                      24144    7                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3
                      24145    2                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3
                      24145    7                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3
                      24145    F                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3
                      24146    2                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3
                      24146    7                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3
                      24147    2                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3




Updated: 09/22/2006                                                                                                     Page: 54 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                             PA IND PAC
                      24147    7                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA                  N     3
                      24147    F                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA                  N     3
                      24148    2                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA                  N     3
                      24148    7                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA                  N     3
                      24149    2                      RADICAL RESECTION OF CAPSULE/SOFT TISSUE/HETEROTOPIC BONE ELBOW     N     3
                      24149    7                      RADICAL RESECTION OF ELBOW                                          N     3
                      24149    8                      RADICAL RESECTION OF ELBOW                                          N     3
                      24150    2                      RADICAL RESECTION FOR TUMOR, SHAFT OR DISTAL HUMER                  N     3
                      24150    7                      RADICAL RESECTION FOR TUMOR, SHAFT OR DISTAL HUMER                  N     3
                      24151    2                      RADICAL RESECTION FOR TUMOR, SHAFT OR DISTAL HUMER                  N     3
                      24151    7                      RADICAL RESECTION FOR TUMOR, SHAFT OR DISTAL HUMER                  N     3
                      24152    2                      RADICAL RESECTION FOR TUMOR, RADIAL HEAD OR NECK;                   N     3
                      24152    7                      RADICAL RESECTION FOR TUMOR, RADIAL HEAD OR NECK;                   N     3
                      24153    2                      RADICAL RESECTION FOR TUMOR, RADIAL HEAD OR NECK;W                  N     3
                      24153    7                      RADICAL RESECTION FOR TUMOR, RADIAL HEAD OR NECK;W                  N     3
                      24155    2                      RESECTION OF ELBOW JOINT (ARTHRECTOMY)                              N     3
                      24155    7                      RESECTION OF ELBOW JOINT (ARTHRECTOMY)                              N     3
                      24155    F                      RESECTION OF ELBOW JOINT (ARTHRECTOMY)                              N     3
                      24160    2                      IMPLANT REMOVAL; ELBOW JOINT                                        N     3
                      24160    7                      IMPLANT REMOVAL; ELBOW JOINT                                        N     3
                      24160    F                      IMPLANT REMOVAL; ELBOW JOINT                                        N     3
                      24164    2                      IMPLANT REMOVAL; RADIAL HEAD                                        N     3
                      24164    7                      IMPLANT REMOVAL; RADIAL HEAD                                        N     3
                      24164    F                      IMPLANT REMOVAL; RADIAL HEAD                                        N     3
                      24200    2                      REMOVAL OF FOREIGN BODY; SUBCUTANEOUS                               N     3
                      24201    2                      REMOVAL OF FOREIGN BODY; DEEP                                       N     3
                      24201    7                      REMOVAL OF FOREIGN BODY; DEEP                                       N     3
                      24201    F                      REMOVAL OF FOREIGN BODY; DEEP                                       N     3
                      24220    2                      INJECTION PROCEDURE FOR ELBOW ARTHROGRAPHY                          N     3
                      24300    2                      MANIPULATION, ELBOW UNDER ANESTHESIA                                N     3
                      24301    2                      MUSCLE OR TENDON TRANSFER, ANY TYPE, SINGLE                         N     3
                      24301    7                      MUSCLE OR TENDON TRANSFER, ANY TYPE, SINGLE                         N     3
                      24301    F                      MUSCLE OR TENDON TRANSFER, ANY TYPE, SINGLE                         N     3
                      24305    2                      TENDON LENGTHENING; SINGLE, EACH                                    N     3
                      24305    7                      TENDON LENGTHENING; SINGLE, EACH                                    N     3
                      24305    F                      TENDON LENGTHENING; SINGLE, EACH                                    N     3
                      24310    2                      TENOTOMY, OPEN, ELBOW TO SHOULDER; SINGLE, EACH                     N     3
                      24310    7                      TENOTOMY, OPEN, ELBOW TO SHOULDER; SINGLE, EACH                     N     3
                      24310    F                      TENOTOMY, OPEN, ELBOW TO SHOULDER; SINGLE, EACH                     N     3
                      24320    2                      TENOPLASTY, WITH MUSCLE TRANSFER, WITH OR WITHOUT                   N     3
                      24320    7                      TENOPLASTY, WITH MUSCLE TRANSFER, WITH OR WITHOUT                   N     3
                      24320    F                      TENOPLASTY, WITH MUSCLE TRANSFER, WITH OR WITHOUT                   N     3
                      24330    2                      FLEXOR-PLASTY, ELBOW, (EG, STEINDLER TYPE ADVANCEM                  N     3
                      24330    7                      FLEXOR-PLASTY, ELBOW, (EG, STEINDLER TYPE ADVANCEM                  N     3
                      24330    F                      FLEXOR-PLASTY, ELBOW, (EG, STEINDLER TYPE ADVANCEM                  N     3
                      24331    2                      FLEXOR-PLASTY, ELBOW, (EG, STEINDLER TYPE ADVANCEM                  N     3
                      24331    7                      FLEXOR-PLASTY, ELBOW, (EG, STEINDLER TYPE ADVANCEM                  N     3




Updated: 09/22/2006                                                                                                                  Page: 55 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      24331    F                      FLEXOR-PLASTY, ELBOW, (EG, STEINDLER TYPE ADVANCEM                    N     3
                      24332    2                      TENOLYSIS, TRICEPS                                                    N     3
                      24340    2                      TENODESIS FOR RUPTURE OF BICEPS TENDON AT ELBOW                       N     3
                      24340    7                      TENODESIS FOR RUPTURE OF BICEPS TENDON AT ELBOW                       N     3
                      24340    F                      TENODESIS FOR RUPTURE OF BICEPS TENDON AT ELBOW                       N     3
                      24341    2                      REPAIR,TENDON/MUSCLE,UPPER ARM/ELBOW,EA.TENDON/MUSCLE PRIM OR SEC     N     3
                      24341    7                      REPAIR TENDON/MUSCLE ARM                                              N     3
                      24341    8                      REPAIR TENDON/MUSCLE ARM                                              N     3
                      24341    F                      REPAIR,TENDON/MUSCLE,UPPER ARM/ELBOW,EA.TENDON/MUSCLE PRIM OR SEC     N     3
                      24342    2                      REINSERTION OF RUPTURED BICEPS TENDON, DISTAL, WIT                    N     3
                      24342    7                      REINSERTION OF RUPTURED BICEPS TENDON, DISTAL, WIT                    N     3
                      24342    F                      REINSERTION OF RUPTURED BICEPS TENDON, DISTAL, WIT                    N     3
                      24343    1                      REPAIR LATERAL COLLATERAL                                             N     3
                      24343    2                      REPAIR LATERAL COLLATERAL LIGAMENT, ELBOW W/LOCAL TISSUE              N     3
                      24344    2                      RECONSTRUCTION LATERAL COLLATERAL LIGAMENT, ELBOW, W/TENDON GRAFT     N     3
                      24344    8                      RECONSTRUCTION LATERAL COLLATERAL LIGAMENT, ELBOW WITH TENDON         N     3
                      24345    2                      REPAIR MEDIAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE           N     3
                      24345    F                      REPAIR MEDIAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE           N     3
                      24346    2                      RECON MEDIAL COLLAT LIGAMENT, ELBOW W/ TENDON GRAFT                   N     3
                      24346    7                      OPEN TRTMNT OF HUMERAL SUPRACONDYLAR OR TRANSCOND                     N     3
                      24350    2                      FASCIOTOMY, LATERAL OR MEDIAL (EG, ''TENNIS ELBOW'                    N     3
                      24350    7                      FASCIOTOMY, LATERAL OR MEDIAL (EG, ''TENNIS ELBOW'                    N     3
                      24350    F                      FASCIOTOMY, LATERAL OR MEDIAL (EG, ''TENNIS ELBOW'                    N     3
                      24351    2                      FASCIOTOMY, LATERAL OR MEDIAL (EG, ''TENNIS ELBOW'                    N     3
                      24351    7                      FASCIOTOMY, LATERAL OR MEDIAL (EG, ''TENNIS ELBOW'                    N     3
                      24351    F                      FASCIOTOMY, LATERAL OR MEDIAL (EG, ''TENNIS ELBOW'                    N     3
                      24352    2                      FASCIOTOMY, LATERAL OR MEDIAL (EG, ''TENNIS ELBOW'                    N     3
                      24352    7                      FASCIOTOMY, LATERAL OR MEDIAL (EG, ''TENNIS ELBOW'                    N     3
                      24352    F                      FASCIOTOMY, LATERAL OR MEDIAL (EG, ''TENNIS ELBOW'                    N     3
                      24354    2                      FASCIOTOMY, LATERAL OR MEDIAL (EG, ''TENNIS ELBOW'                    N     3
                      24354    7                      FASCIOTOMY, LATERAL OR MEDIAL (EG, ''TENNIS ELBOW'                    N     3
                      24354    F                      FASCIOTOMY, LATERAL OR MEDIAL (EG, ''TENNIS ELBOW'                    N     3
                      24356    2                      FASCIOTOMY LAT OR MED W PART OSTECTOMY                                N     3
                      24356    7                      FASCIOTOMY LAT OR MED W PART OSTECTOMY                                N     3
                      24356    8                      FASCIOTOMY LAT OR MED W PART OSTECTOMY                                N     3
                      24356    F                      FASCIOTOMY LAT OR MED W PART OSTECTOMY                                N     3
                      24360    2                      ARTHROPLASTY, ELBOW; WITH MEMBRANE                                    N     3
                      24360    7                      ARTHROPLASTY, ELBOW; WITH MEMBRANE                                    N     3
                      24360    8                      ARTHROPLASTY, ELBOW; WITH MEMBRANE                                    N     3
                      24360    F                      ARTHROPLASTY, ELBOW; WITH MEMBRANE                                    N     3
                      24361    2                      ARTHROPLASTY ELBOW W DISTAL HUMERAL PROSTH REPLACE                    N     3
                      24361    7                      ARTHROPLASTY ELBOW W DISTAL HUMERAL PROSTH REPLACE                    N     3
                      24361    F                      ARTHROPLASTY ELBOW W DISTAL HUMERAL PROSTH REPLACE                    N     3
                      24362    2                      ARTHROPLASTY, ELBOW; WITH IMPLANT AND FASCIA LATA                     N     3
                      24362    7                      ARTHROPLASTY, ELBOW; WITH IMPLANT AND FASCIA LATA                     N     3
                      24362    F                      ARTHROPLASTY, ELBOW; WITH IMPLANT AND FASCIA LATA                     N     3
                      24363    2                      ARTHROPLASTY, ELBOW; WITH DISTAL HUMERUS AND PROXI                    N     3




Updated: 09/22/2006                                                                                                                    Page: 56 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      24363    7                      ARTHROPLASTY, ELBOW; WITH DISTAL HUMERUS AND PROXI     N     3
                      24363    8                      ARTHROPLASTY, ELBOW; WITH DISTAL HUMERUS AND PROXI     N     3
                      24363    F                      ARTHROPLASTY, ELBOW; WITH DISTAL HUMERUS AND PROXI     N     3
                      24365    2                      ARTHROPLASTY, RADIAL HEAD;                             N     3
                      24365    7                      ARTHROPLASTY, RADIAL HEAD;                             N     3
                      24365    F                      ARTHROPLASTY, RADIAL HEAD;                             N     3
                      24366    2                      ARTHROPLASTY, RADIAL HEAD; WITH IMPLANT                N     3
                      24366    7                      ARTHROPLASTY, RADIAL HEAD; WITH IMPLANT                N     3
                      24366    8                      ARTHROPLASTY, RADIAL HEAD; WITH IMPLANT                N     3
                      24366    F                      ARTHROPLASTY, RADIAL HEAD; WITH IMPLANT                N     3
                      24400    2                      OSTEOTOMY, HUMERUS, WITH OR WITHOUT INTERNAL FIXAT     N     3
                      24400    7                      OSTEOTOMY, HUMERUS, WITH OR WITHOUT INTERNAL FIXAT     N     3
                      24400    8                      OSTEOTOMY, HUMERUS, WITH OR WITHOUT INTERNAL FIXAT     N     3
                      24400    F                      OSTEOTOMY, HUMERUS, WITH OR WITHOUT INTERNAL FIXAT     N     3
                      24410    2                      MULTIPLE OSTEOTOMIES WITH REALIGNMENT ON INTRAMEDU     N     3
                      24410    7                      MULTIPLE OSTEOTOMIES WITH REALIGNMENT ON INTRAMEDU     N     3
                      24410    8                      MULTIPLE OSTEOTOMIES WITH REALIGNMENT ON INTRAMEDU     N     3
                      24410    F                      MULTIPLE OSTEOTOMIES WITH REALIGNMENT ON INTRAMEDU     N     3
                      24420    2                      OSTEOPLASTY, HUMERUS (EG, SHORTENING OR LENGTHENIN     N     3
                      24420    7                      OSTEOPLASTY, HUMERUS (EG, SHORTENING OR LENGTHENIN     N     3
                      24420    8                      OSTEOPLASTY, HUMERUS (EG, SHORTENING OR LENGTHENIN     N     3
                      24420    F                      OSTEOPLASTY, HUMERUS (EG, SHORTENING OR LENGTHENIN     N     3
                      24430    2                      REPAIR OF NONUNION OR MALUNION, HUMERUS; WITHOUT G     N     3
                      24430    7                      REPAIR OF NONUNION OR MALUNION, HUMERUS; WITHOUT G     N     3
                      24430    8                      REPAIR OF NONUNION OR MALUNION, HUMERUS; WITHOUT G     N     3
                      24430    F                      REPAIR OF NONUNION OR MALUNION, HUMERUS; WITHOUT G     N     3
                      24435    2                      REPAIR OF NONUNION OR MALUNION, HUMERUS; WITH ILIA     N     3
                      24435    7                      REPAIR OF NONUNION OR MALUNION, HUMERUS; WITH ILIA     N     3
                      24435    8                      REPAIR OF NONUNION OR MALUNION, HUMERUS; WITH ILIA     N     3
                      24435    F                      REPAIR OF NONUNION OR MALUNION, HUMERUS; WITH ILIA     N     3
                      24470    2                      HEMIEPIPHYSEAL ARREST (EG, FOR CUBITUS VARUS OR VA     N     3
                      24470    7                      HEMIEPIPHYSEAL ARREST (EG, FOR CUBITUS VARUS OR VA     N     3
                      24470    F                      HEMIEPIPHYSEAL ARREST (EG, FOR CUBITUS VARUS OR VA     N     3
                      24495    2                      DECOMPRESSION FASCIOTOMY, FOREARM, WITH BRACHIAL A     N     3
                      24495    7                      DECOMPRESSION FASCIOTOMY, FOREARM, WITH BRACHIAL A     N     3
                      24495    8                      DECOMPRESSION FASCIOTOMY, FOREARM, WITH BRACHIAL A     N     3
                      24495    F                      DECOMPRESSION FASCIOTOMY, FOREARM, WITH BRACHIAL A     N     3
                      24498    7                      PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING      N     3
                      24498    F                      PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING      N     3
                      24500    2                      TREATMENT OF CLOSED HUMERAL SHAFT FRACTURE; WITHOU     N     3
                      24500    7                      TREATMENT OF CLOSED HUMERAL SHAFT FRACTURE; WITHOU     N     3
                      24500    F                      TREATMENT OF CLOSED HUMERAL SHAFT FRACTURE; WITHOU     N     3
                      24505    2                      TREATMENT OF CLOSED HUMERAL SHAFT FRACTURE; WITH M     N     3
                      24505    7                      TREATMENT OF CLOSED HUMERAL SHAFT FRACTURE; WITH M     N     3
                      24505    F                      TREATMENT OF CLOSED HUMERAL SHAFT FRACTURE; WITH M     N     3
                      24515    2                      OPEN TREATMENT OF CLOSED OR OPEN HUMERAL SHAFT FRA     N     3
                      24515    7                      OPEN TREATMENT OF CLOSED OR OPEN HUMERAL SHAFT FRA     N     3




Updated: 09/22/2006                                                                                                     Page: 57 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      24515    8                      OPEN TREATMENT OF CLOSED OR OPEN HUMERAL SHAFT FRA                    N     3
                      24515    F                      OPEN TREATMENT OF CLOSED OR OPEN HUMERAL SHAFT FRA                    N     3
                      24516    2                      OPEN TREATMENT OF HUMERAL SHAFT FRACTURE, WITH INS                    N     3
                      24516    7                      OPEN TRTMNT OF HUMERAL SHAFT FRACT, WITH INSERTION                    N     3
                      24516    8                      OPEN TRTMNT OF HUMERAL SHAFT FRACT, WITH INSERTION                    N     3
                      24530    2                      TREATMENT OF CLOSED SUPRACONDYLAR OR TRANSCONDYLAR                    N     3
                      24530    7                      TREATMENT OF CLOSED SUPRACONDYLAR OR TRANSCONDYLAR                    N     3
                      24530    F                      TREATMENT OF CLOSED SUPRACONDYLAR OR TRANSCONDYLAR                    N     3
                      24535    2                      TREATMENT OF CLOSED SUPRACONDYLAR OR TRANSCONDYLAR                    N     3
                      24535    7                      TREATMENT OF CLOSED SUPRACONDYLAR OR TRANSCONDYLAR                    N     3
                      24535    F                      TREATMENT OF CLOSED SUPRACONDYLAR OR TRANSCONDYLAR                    N     3
                      24538    2                      TREATMENT OF CLOSED SUPRACONDYLAR OR TRANSCONDYLAR                    N     3
                      24538    7                      TREATMENT OF CLOSED SUPRACONDYLAR OR TRANSCONDYLAR                    N     3
                      24538    8                      TREATMENT OF CLOSED SUPRACONDYLAR OR TRANSCONDYLAR                    N     3
                      24538    F                      TREATMENT OF CLOSED SUPRACONDYLAR OR TRANSCONDYLAR                    N     3
                      24545    2                      OPEN TREATMENT OF CLOSED OR OPEN SUPRACONDYLAR FRA                    N     3
                      24545    7                      OPEN TREATMENT OF CLOSED OR OPEN SUPRACONDYLAR FRA                    N     3
                      24545    8                      OPEN TREATMENT OF CLOSED OR OPEN SUPRACONDYLAR FRA                    N     3
                      24545    F                      OPEN TREATMENT OF CLOSED OR OPEN SUPRACONDYLAR FRA                    N     3
                      24546    2                      OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCO                    N     3
                      24546    8                      OPEN TREATMENT OF HUMERAL SUUPRACONDYLAR OR TRANSCO                   N     3
                      24546    F                      OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCO                    N     3
                      24560    2                      TREATMENT OF CLOSED EPICONDYLAR FRACTURE, MEDIAL O                    N     3
                      24560    7                      TREATMENT OF CLOSED EPICONDYLAR FRACTURE, MEDIAL O                    N     3
                      24560    F                      TREATMENT OF CLOSED EPICONDYLAR FRACTURE, MEDIAL O                    N     3
                      24565    2                      TREATMENT OF CLOSED EPICONDYLAR FRACTURE, MEDIAL O                    N     3
                      24565    7                      TREATMENT OF CLOSED EPICONDYLAR FRACTURE, MEDIAL O                    N     3
                      24565    F                      TREATMENT OF CLOSED EPICONDYLAR FRACTURE, MEDIAL O                    N     3
                      24566    2                      PERCUTANEOUS SKELETAL FIXATION OF HUMERAL EPICONDY                    N     3
                      24566    7                      ANESTHESIA, PERCUTANEOUS SKELETAL FIXATION OF HUMERAL EPICONDYLAR     N     3
                      24566    F                      PERCUTANEOUS SKELETAL FIXATION OF HUMERAL EPICONDY                    N     3
                      24575    2                      OPEN TREATMENT OF CLOSED OR OPEN EPICONDYLAR FRACT                    N     3
                      24575    7                      OPEN TREATMENT OF CLOSED OR OPEN EPICONDYLAR FRACT                    N     3
                      24575    8                      OPEN TREATMENT OF CLOSED OR OPEN EPICONDYLAR FRACT                    N     3
                      24575    F                      OPEN TREATMENT OF CLOSED OR OPEN EPICONDYLAR FRACT                    N     3
                      24576    2                      TREATMENT OF CLOSED CONDYLAR FRACTURE, MEDIAL OR L                    N     3
                      24576    F                      TREATMENT OF CLOSED CONDYLAR FRACTURE, MEDIAL OR L                    N     3
                      24577    2                      TREATMENT OF CLOSED CONDYLAR FRACTURE, MEDIAL OR L                    N     3
                      24577    7                      TREATMENT OF CLOSED CONDYLAR FRACTURE, MEDIAL OR L                    N     3
                      24577    F                      TREATMENT OF CLOSED CONDYLAR FRACTURE, MEDIAL OR L                    N     3
                      24579    2                      OPEN TREATMENT OF CLOSED OR OPEN CONDYLAR FRACTURE                    N     3
                      24579    7                      OPEN TREATMENT OF CLOSED OR OPEN CONDYLAR FRACTURE                    N     3
                      24579    8                      OPEN TREATMENT OF CLOSED OR OPEN CONDYLAR FRACTURE                    N     3
                      24579    F                      OPEN TREATMENT OF CLOSED OR OPEN CONDYLAR FRACTURE                    N     3
                      24582    2                      PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR                    N     3
                      24582    F                      PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR                    N     3
                      24586    2                      OPEN TREATMENT OF CLOSED OR OPEN COMMINUTED ELBOW                     N     3




Updated: 09/22/2006                                                                                                                    Page: 58 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      24586    7                      OPEN TREATMENT OF CLOSED OR OPEN COMMINUTED ELBOW      N     3
                      24586    F                      OPEN TREATMENT OF CLOSED OR OPEN COMMINUTED ELBOW      N     3
                      24587    2                      OPEN TREATMENT OF CLOSED OR OPEN COMMINUTED ELBOW      N     3
                      24587    7                      OPEN TREATMENT OF CLOSED OR OPEN COMMINUTED ELBOW      N     3
                      24587    F                      OPEN TREATMENT OF CLOSED OR OPEN COMMINUTED ELBOW      N     3
                      24600    2                      TREATMENT OF CLOSED ELBOW DISLOCATION; WITHOUT ANE     N     3
                      24600    F                      TREATMENT OF CLOSED ELBOW DISLOCATION; WITHOUT ANE     N     3
                      24605    2                      TREATMENT OF CLOSED ELBOW DISLOCATION; REQUIRING A     N     3
                      24605    7                      TREATMENT OF CLOSED ELBOW DISLOCATION; REQUIRING A     N     3
                      24605    F                      TREATMENT OF CLOSED ELBOW DISLOCATION; REQUIRING A     N     3
                      24615    2                      OPEN TREATMENT OF CLOSED OR OPEN ELBOW DISLOCATION     N     3
                      24615    7                      OPEN TREATMENT OF CLOSED OR OPEN ELBOW DISLOCATION     N     3
                      24615    8                      OPEN TREATMENT OF CLOSED OR OPEN ELBOW DISLOCATION     N     3
                      24615    F                      OPEN TREATMENT OF CLOSED OR OPEN ELBOW DISLOCATION     N     3
                      24620    2                      TREATMENT OF CLOSED MONTEGGIA TYPE OF FRACTURE DIS     N     3
                      24620    7                      TREAT OF CLOSED MONTEGGIA TYPE OF FRACTURE,DISLOC      N     3
                      24620    F                      TREATMENT OF CLOSED MONTEGGIA TYPE OF FRACTURE DIS     N     3
                      24635    2                      OPEN TREATMENT OF CLOSED OR OPEN MONTEGGIA TYPE OF     N     3
                      24635    7                      OPEN TREATMENT OF CLOSED OR OPEN MONTEGGIA TYPE OF     N     3
                      24635    8                      OPEN TREATMENT OF CLOSED OR OPEN MONTEGGIA TYPE OF     N     3
                      24635    F                      OPEN TREATMENT OF CLOSED OR OPEN MONTEGGIA TYPE OF     N     3
                      24640    2                      TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, "NU     N     3
                      24640    7                      TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, "NU     N     3
                      24650    2                      TREATMENT OF CLOSED RADIAL HEAD OR NECK FRACTURE;      N     3
                      24650    7                      TREATMENT OF CLOSED RADIAL HEAD OR NECK FRACTURE;      N     3
                      24655    2                      TREATMENT OF CLOSED RADIAL HEAD OR NECK FRACTURE;      N     3
                      24655    7                      TREATMENT OF CLOSED RADIAL HEAD OR NECK FRACTURE;      N     3
                      24655    F                      TREATMENT OF CLOSED RADIAL HEAD OR NECK FRACTURE;      N     3
                      24665    2                      OPEN TREAT OF CLOSED OR OPEN RADIAL HEAD OR NECK F     N     3
                      24665    7                      OPEN TREAT OF CLOSED OR OPEN RADIAL HEAD OR NECK F     N     3
                      24665    8                      OPEN TREAT OF CLOSED OR OPEN RADIAL HEAD OR NECK F     N     3
                      24665    F                      OPEN TREAT OF CLOSED OR OPEN RADIAL HEAD OR NECK F     N     3
                      24666    2                      OPEN TREAT OF CLOSED OR OPEN RAD HD OR NECK FRAC W     N     3
                      24666    7                      OPEN TREAT OF CLOSED OR OPEN RAD HD OR NECK FRAC W     N     3
                      24666    8                      OPEN TREAT OF CLOSED OR OPEN RAD HD OR NECK FRAC W     N     3
                      24666    F                      OPEN TREAT OF CLOSED OR OPEN RAD HD OR NECK FRAC W     N     3
                      24670    2                      TREATMENT OF CLOSED ULNAR FRACTURE, PROXIMAL END (     N     3
                      24670    7                      TREATMENT OF CLOSED ULNAR FRACTURE, PROXIMAL END (     N     3
                      24670    F                      TREATMENT OF CLOSED ULNAR FRACTURE, PROXIMAL END (     N     3
                      24675    2                      TREATMENT OF CLOSED ULNAR FRACTURE, PROXIMAL END (     N     3
                      24675    7                      TREATMENT OF CLOSED ULNAR FRACTURE, PROXIMAL END (     N     3
                      24675    F                      TREATMENT OF CLOSED ULNAR FRACTURE, PROXIMAL END (     N     3
                      24685    2                      OPEN TREAT. OF CLOS OR OPEN ULNAR FRAC, PROX END (     N     3
                      24685    7                      OPEN TREAT. OF CLOS OR OPEN ULNAR FRAC, PROX END (     N     3
                      24685    8                      OPEN TREAT. OF CLOS OR OPEN ULNAR FRAC, PROX END (     N     3
                      24685    F                      OPEN TREAT. OF CLOS OR OPEN ULNAR FRAC, PROX END (     N     3
                      24700    2                      MANIPULATION UNDER GENERAL ANESTHESIA (INCLUDES AP     N     3




Updated: 09/22/2006                                                                                                     Page: 59 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      24700    7                      MANIPULATION UNDER GENERAL ANESTHESIA (INCLUDES AP                    N     3
                      24800    2                      ARTHRODESIS, ELBOW JOINT; WITH OR W/O LOCAL OR HOM                    N     3
                      24800    7                      ARTHRODESIS, ELBOW JOINT; WITH OR W/O LOCAL OR HOM                    N     3
                      24800    8                      ARTHRODESIS, ELBOW JOINT; WITH OR W/O LOCAL OR HOM                    N     3
                      24800    F                      ARTHRODESIS, ELBOW JOINT; WITH OR W/O LOCAL OR HOM                    N     3
                      24802    2                      ARTHRODESIS, ELBOW JOINT; W/ PRIMARY AUTOGENOUS BO                    N     3
                      24802    7                      ARTHRODESIS, ELBOW JOINT; W/ PRIMARY AUTOGENOUS BO                    N     3
                      24802    F                      ARTHRODESIS, ELBOW JOINT; W/ PRIMARY AUTOGENOUS BO                    N     3
                      24813    2                      PLACEM.OF FEMOR.PROSTHET.GRAFT DURING ENDOVASCULAR AORT.ANEUR.        N     3
                      24900    2                      AMPUTATION, ARM THROUGH HUMERUS; WITH PRIMARY CLOS                    N     3
                      24900    7                      AMPUTATION, ARM THROUGH HUMERUS; WITH PRIMARY CLOS                    N     3
                      24900    8                      AMPUTATION, ARM THROUGH HUMERUS; WITH PRIMARY CLOS                    N     3
                      24920    2                      AMPUTATION, ARM THROUGH HUMERUS; OPEN, FLAP OR CIR                    N     3
                      24920    7                      AMPUTATION, ARM THROUGH HUMERUS; OPEN, FLAP OR CIR                    N     3
                      24920    8                      AMPUTATION, ARM THROUGH HUMERUS; OPEN, FLAP OR CIR                    N     3
                      24925    2                      AMPUTATION, ARM THROUGH HUMERUS; SECONDARY CLOSURE                    N     3
                      24925    7                      AMPUTATION, ARM THROUGH HUMERUS; SECONDARY CLOSURE                    N     3
                      24925    F                      AMPUTATION, ARM THROUGH HUMERUS; SECONDARY CLOSURE                    N     3
                      24930    2                      AMPUTATION, ARM THROUGH HUMERUS; REAMPUTATION                         N     3
                      24930    7                      AMPUTATION, ARM THROUGH HUMERUS; REAMPUTATION                         N     3
                      24931    2                      AMPUTATION, ARM                                                       N     3
                      24931    7                      AMPUTATION, ARM THROUGH HUMERUS; WITH IMPLANT                         N     3
                      24935    2                      STUMP ELONGATION                                                      N     3
                      24935    7                      STUMP ELONGATION                                                      N     3
                      24940    2                      CINEPLASTY, UPPER EXTREMITY, COMPLETE PROCEDURE                       N     3
                      24940    7                      CINEPLASTY, UPPER EXTREMITY, COMPLETE PROCEDURE                       N     3
                      24999    7                      UNLISTED PROCEDURE, HUMERUS OR ELBOW                                  N     3
                      25000    2                      TENDON SHEATH INCISION; AT RADIAL STYLOID FOR DEQU                    N     3
                      25000    7                      TENDON SHEATH INCISION; AT RADIAL STYLOID FOR DEQU                    N     3
                      25000    F                      TENDON SHEATH INCISION; AT RADIAL STYLOID FOR DEQU                    N     3
                      25001    2                      INCISE FELXOR RARPI RADIALIS                                          N     3
                      25020    2                      DECOMPRESSION FASCIOTOMY, FLEXOR AND/OR EXTENSOR C                    N     3
                      25020    7                      DECOMPRESSION FASCIOTOMY, FLEXOR AND/OR EXTENSOR C                    N     3
                      25020    8                      DECOMPRESSION FASCIOTOMY, FLEXOR AND/OR EXTENSOR C                    N     3
                      25020    F                      DECOMPRESSION FASCIOTOMY, FLEXOR AND/OR EXTENSOR C                    N     3
                      25023    7                      DECOMP FASCIOTOMY, FLEX AND/OR EXTENS COMPART W/DE                    N     3
                      25024    2                      DECOMPRESSION FACIOTOMY FOREARM AND/OR WRIST FLEXOR AND EXTENSOR      N     3
                      25024    F                      DECOMPRESSION FACIOTOMY FOREARM AND/OR WRIST FLEXOR AND EXTENSOR      N     3
                      25025    2                      DECOMPRESSION FASCIOTOMY FOREARM AND/OR WRIST, FLEXOR AND EXTENSO     N     3
                      25028    2                      INCISION AND DRAINAGE; DEEP ABSCESS OR HEMATOMA                       N     3
                      25028    7                      I&D DEEP ABCESS OR HEMATOMA FOREAM OR WRIST                           N     3
                      25028    F                      INCISION AND DRAINAGE; DEEP ABSCESS OR HEMATOMA                       N     3
                      25031    7                      I&D INFECTED BURSA-FOREARM OR WRIST                                   N     3
                      25031    F                      INCISION AND DRAINAGE; INFECTED BURSA                                 N     3
                      25035    2                      INCISION, DEEP, WITH OPENING OF CORTEX (EG, FOR OS                    N     3
                      25035    7                      INCISION, DEEP, WITH OPENING OF CORTEX (EG, FOR OS                    N     3
                      25035    8                      INCISION, DEEP, WITH OPENING OF CORTEX (EG, FOR OS                    N     3




Updated: 09/22/2006                                                                                                                    Page: 60 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      25035    F                      INCISION, DEEP, WITH OPENING OF CORTEX (EG, FOR OS     N     3
                      25036    2                      INCISION, DEEP, WITH OPENING OF CORTEX FOR OSTEOMY     N     3
                      25036    7                      INCISION, DEEP, WITH OPENING OF CORTEX FOR OSTEOMY     N     3
                      25040    2                      ARTHROTOMY W/EXPLOR, DRAIN, OR REM OF LOOS OR FORE     N     3
                      25040    7                      ARTHROTOMY W/EXPLOR, DRAIN, OR REM OF LOOS OR FORE     N     3
                      25040    F                      ARTHROTOMY W/EXPLOR, DRAIN, OR REM OF LOOS OR FORE     N     3
                      25041    2                      ARTHROTOMY WITH EXPLORATION, DRAINAGE, OR REMOVAL      N     3
                      25041    7                      ARTHROTOMY WITH EXPLORATION, DRAINAGE, OR REMOVAL      N     3
                      25065    2                      BIOPSY, SOFT TISSUES; SUPERFICIAL                      N     3
                      25065    7                      ANESTHESIA, BIOPSY, SOFT TISSUES, SUPERFICIAL          N     3
                      25066    2                      BIOPSY, SOFT TISSUES; DEEP                             N     3
                      25066    7                      BIOPSY FOREARM OR WRIST DEEP                           N     3
                      25066    F                      BIOPSY, SOFT TISSUES; DEEP                             N     3
                      25075    2                      EXCISION, BENIGN TUMOR; SUBCUTANEOUS                   N     3
                      25075    7                      ANESTH FOR EXCISION BENIGN SUBCUTAN TUMOR WRST/ARM     N     3
                      25075    F                      EXCISION, BENIGN TUMOR; SUBCUTANEOUS                   N     3
                      25076    2                      EXCISION, BENIGN TUMOR; DEEP, SUBFASCIAL OR INTRAM     N     3
                      25076    7                      EXCISION, BENIGN TUMOR; DEEP, SUBFASCIAL OR INTRAM     N     3
                      25076    F                      EXCISION, BENIGN TUMOR; DEEP, SUBFASCIAL OR INTRAM     N     3
                      25077    7                      RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM     N     3
                      25077    F                      RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM     N     3
                      25085    2                      CAPSULOTOMY, WRIST (EG, FOR CONTRACTURE)               N     3
                      25085    7                      CAPSULOTOMY, WRIST (EG, FOR CONTRACTURE)               N     3
                      25085    8                      CAPSULOTOMY, WRIST (EG, FOR CONTRACTURE)               N     3
                      25085    F                      CAPSULOTOMY, WRIST (EG, FOR CONTRACTURE)               N     3
                      25100    2                      ARTHROTOMY, WRIST JOINT; FOR BIOPSY                    N     3
                      25100    7                      ARTHROTOMY, WRIST JOINT; FOR BIOPSY                    N     3
                      25100    F                      ARTHROTOMY, WRIST JOINT; FOR BIOPSY                    N     3
                      25101    2                      ARTHROTOMY, WRIST JOINT; W/EXPLO, W/ OR W/O BIOPSY     N     3
                      25101    7                      ARTHROTOMY, WRIST JOINT; W/EXPLO, W/ OR W/O BIOPSY     N     3
                      25101    F                      ARTHROTOMY, WRIST JOINT; W/EXPLO, W/ OR W/O BIOPSY     N     3
                      25105    2                      ARTHROTOMY, WRIST JOINT; FOR SYNOVECTOMY               N     3
                      25105    7                      ARTHROTOMY, WRIST JOINT; FOR SYNOVECTOMY               N     3
                      25105    F                      ARTHROTOMY, WRIST JOINT; FOR SYNOVECTOMY               N     3
                      25107    2                      ARTHROTOMY, DISTAL RADIOULNAR JOINT FOR EXCISION T     N     3
                      25107    7                      ARTHROTOMY, DISTAL RADIOULNAR JOINT FOR EXCISION T     N     3
                      25107    F                      ARTHROTOMY, DISTAL RADIOULNAR JOINT FOR EXCISION T     N     3
                      25110    2                      EXCISION, LESION OF TENDON SHEATH                      N     3
                      25110    7                      EXCISION, LESION OF TENDON SHEATH                      N     3
                      25110    F                      EXCISION, LESION OF TENDON SHEATH                      N     3
                      25111    2                      EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); PRI     N     3
                      25111    7                      EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); PRI     N     3
                      25111    F                      EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); PRI     N     3
                      25112    2                      EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); REC     N     3
                      25112    7                      EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); REC     N     3
                      25112    F                      EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); REC     N     3
                      25115    2                      RADICAL EXCISION OF BURSA, SYNOVIA OF WRIST, OR FO     N     3




Updated: 09/22/2006                                                                                                     Page: 61 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      25115    7                      RADICAL EXCISION OF BURSA, SYNOVIA OF WRIST, OR FO     N     3
                      25115    F                      RADICAL EXCISION OF BURSA, SYNOVIA OF WRIST, OR FO     N     3
                      25116    2                      RADICAL EXCISION OF BURSA, SYNOVIA OF WRIST, OR FO     N     3
                      25116    7                      RADICAL EXCISION OF BURSA, SYNOVIA OF WRIST, OR FO     N     3
                      25116    F                      RADICAL EXCISION OF BURSA, SYNOVIA OF WRIST, OR FO     N     3
                      25118    2                      SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE     N     3
                      25118    7                      SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE     N     3
                      25118    8                      SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE     N     3
                      25118    F                      SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE     N     3
                      25119    2                      SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE     N     3
                      25119    7                      SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE     N     3
                      25119    F                      SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE     N     3
                      25120    2                      EXCIS OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF     N     3
                      25120    7                      EXCIS OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF     N     3
                      25120    8                      EXCIS OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF     N     3
                      25120    F                      EXCIS OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF     N     3
                      25125    2                      EXCIS OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF     N     3
                      25125    7                      EXCIS OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF     N     3
                      25125    8                      EXCIS OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF     N     3
                      25125    F                      EXCIS OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF     N     3
                      25126    2                      EXCIS OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF     N     3
                      25126    7                      EXCIS OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF     N     3
                      25126    F                      EXCIS OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF     N     3
                      25130    2                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      25130    7                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      25130    F                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      25135    2                      EXCIS OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF     N     3
                      25135    7                      EXCIS OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF     N     3
                      25135    8                      EXCIS OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF     N     3
                      25135    F                      EXCIS OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF     N     3
                      25136    2                      EXCIS OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF     N     3
                      25136    7                      EXCIS OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF     N     3
                      25136    F                      EXCIS OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF     N     3
                      25145    2                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS;      N     3
                      25145    7                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS;      N     3
                      25145    F                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS;      N     3
                      25146    2                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS;      N     3
                      25146    7                      SEQUESTRECTOMY FOR OSTEOMYELITIS OR BONE ABSCESS;      N     3
                      25150    2                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3
                      25150    7                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3
                      25150    F                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3
                      25151    2                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3
                      25151    7                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3
                      25151    F                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3
                      25153    2                      PARTIAL EXCIS OF BONE (CRATERIZ, SAUCERIZ OR DIAPH     N     3
                      25153    7                      PARTIAL EXCIS OF BONE (CRATERIZ, SAUCERIZ OR DIAPH     N     3
                      25170    7                      RADICAL RESECTION FOR TUMOR, RADIUS OR ULNA            N     3




Updated: 09/22/2006                                                                                                     Page: 62 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      25175    2                      RECONSTRUCTION,BIFRONTAL,SUPERIOR-LATERAL ORBITAL RIMS AND LOWER      N     3
                      25210    2                      CARPECTOMY; ONE BONE                                                  N     3
                      25210    7                      CARPECTOMY; ONE BONE                                                  N     3
                      25210    8                      CARPECTOMY; ONE BONE                                                  N     3
                      25210    F                      CARPECTOMY; ONE BONE                                                  N     3
                      25215    2                      CARPECTOMY; ALL BONES OR PROXIMAL ROW                                 N     3
                      25215    7                      CARPECTOMY; ALL BONES OR PROXIMAL ROW                                 N     3
                      25215    8                      CARPECTOMY; ALL BONES OR PROXIMAL ROW                                 N     3
                      25215    F                      CARPECTOMY; ALL BONES OR PROXIMAL ROW                                 N     3
                      25230    2                      RADIAL STYLOIDECTOMY (SEPARATE PROCEDURE)                             N     3
                      25230    7                      RADIAL STYLOIDECTOMY (SEPARATE PROCEDURE)                             N     3
                      25230    F                      RADIAL STYLOIDECTOMY (SEPARATE PROCEDURE)                             N     3
                      25240    2                      EXCISION DISTAL ULNA (DARRACH TYPE PROCEDURE)                         N     3
                      25240    7                      EXCISION DISTAL ULNA (DARRACH TYPE PROCEDURE)                         N     3
                      25240    F                      EXCISION DISTAL ULNA (DARRACH TYPE PROCEDURE)                         N     3
                      25246    2                      INJECTION PROCEDURE FOR WRIST ARTHROGRAPHY                            N     3
                      25248    2                      EXPLORATION FOR REMOVAL OF DEEP FOREIGN BODY                          N     3
                      25248    7                      EXPLORATION FOR REMOVAL OF DEEP FOREIGN BODY                          N     3
                      25248    F                      EXPLORATION FOR REMOVAL OF DEEP FOREIGN BODY                          N     3
                      25250    2                      REMOVAL OF WRIST PROSTHESIS; (SEPARATE PROCEDURE)                     N     3
                      25250    7                      REMOVAL OF WRIST PROSTHESIS; (SEPARATE PROCEDURE)                     N     3
                      25250    F                      REMOVAL OF WRIST PROSTHESIS; (SEPARATE PROCEDURE)                     N     3
                      25251    2                      COMPLICATED, INCLUDING "TOTAL WRIST"                                  N     3
                      25251    7                      COMPLICATED, INCLUDING "TOTAL WRIST"                                  N     3
                      25251    F                      COMPLICATED, INCLUDING TOTAL WRIST                                    N     3
                      25259    2                      MANIPULATION, WRIST, UNDER ANESTHESIA                                 N     3
                      25260    2                      REPAIR, TENDON OR MUSCLE, FLEXOR; PRIMARY, SINGLE,                    N     3
                      25260    7                      REPAIR, TENDON OR MUSCLE, FLEXOR; PRIMARY, SINGLE,                    N     3
                      25260    8                      REPAIR, TENDON OR MUSCLE, FLEXOR; PRIMARY, SINGLE,                    N     3
                      25260    F                      REPAIR, TENDON OR MUSCLE, FLEXOR; PRIMARY, SINGLE,                    N     3
                      25263    2                      REPAIR TENDON OR MUSCLE FLEXOR; SECONDARY, SINGL                      N     3
                      25263    7                      REPAIR TENDON OR MUSCLE, FLEXOR; SECONDARY, SINGL                     N     3
                      25263    F                      REPAIR TENDON OR MUSCLE FLEXOR; SECONDARY, SINGL                      N     3
                      25265    2                      REPAIR, TENDON OR MUSCLE, FLEXOR; SECONDARY, W/FRE                    N     3
                      25265    7                      REPAIR, TENDON OR MUSCLE, FLEXOR; SECONDARY, W/FRE                    N     3
                      25265    F                      REPAIR, TENDON OR MUSCLE, FLEXOR; SECONDARY, W/FRE                    N     3
                      25270    2                      REPAIR, TENDON OR MUSCLE, EXTENSOR; PRIMARY, SINGLE,EACH TENDON O     N     3
                      25270    7                      REPAIR, TENDON OR MUSCLE, EXTENSOR; PRIMARY, SINGL                    N     3
                      25270    8                      REPAIR, TENDON OR MUSCLE, EXTENSOR; PRIMARY, SINGL                    N     3
                      25270    F                      REPAIR, TENDON OR MUSCLE, EXTENSOR; PRIMARY, SINGLE,EACH TENDON O     N     3
                      25272    2                      REPAIR, TENDON OR MUSCLE, EXTENSOR; SECONDARY, SIN                    N     3
                      25272    7                      REPAIR, TENDON OR MUSCLE, EXTENSOR; SECONDARY, SIN                    N     3
                      25272    F                      REPAIR, TENDON OR MUSCLE, EXTENSOR; SECONDARY, SIN                    N     3
                      25274    2                      REPAIR, TENDON OR MUSCLE, EXTENSOR, SECONDARY, W/                     N     3
                      25274    7                      REPAIR, TENDON OR MUSCLE, EXTENSOR, SECONDARY, W/                     N     3
                      25274    F                      REPAIR, TENDON OR MUSCLE, EXTENSOR, SECONDARY, W/                     N     3
                      25275    2                      REPAIR, TENDOR SHEATH, EXTENSOR, FOREARM AND/OR WRIST WITH FREE       N     3




Updated: 09/22/2006                                                                                                                    Page: 63 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      25275    F                      REPAIR, TENDOR SHEATH, EXTENSOR, FOREARM AND/OR WRIST WITH FREE       N     3
                      25280    2                      LENGTHENING OR SHORTENING OF FLEXOR OR EXTENSOR TE                    N     3
                      25280    7                      LENGTHENING OR SHORTENING OF FLEXOR OR EXTENSOR TE                    N     3
                      25280    8                      LENGTHENING OR SHORTENING OF FLEXOR OR EXTENSOR TE                    N     3
                      25280    F                      LENGTHENING OR SHORTENING OF FLEXOR OR EXTENSOR TE                    N     3
                      25290    2                      TENOTOMY, OPEN, SINGLE, FLEXOR OR EXTENSOR TENDON,                    N     3
                      25290    7                      TENOTOMY, OPEN, SINGLE, FLEXOR OR EXTENSOR TENDON,                    N     3
                      25290    F                      TENOTOMY, OPEN, SINGLE, FLEXOR OR EXTENSOR TENDON,                    N     3
                      25295    2                      TENOLYSIS, SINGLE FLEXOR OR EXTENSOR TENDON, EACH                     N     3
                      25295    7                      TENOLYSIS, SINGLE FLEXOR OR EXTENSOR TENDON, EACH                     N     3
                      25295    F                      TENOLYSIS, SINGLE FLEXOR OR EXTENSOR TENDON, EACH                     N     3
                      25300    2                      TENODESIS AT WRIST; FLEXORS OF FINGERS                                N     3
                      25300    7                      TENODESIS AT WRIST; FLEXORS OF FINGERS                                N     3
                      25300    F                      TENODESIS AT WRIST; FLEXORS OF FINGERS                                N     3
                      25301    2                      TENODESIS AT WRIST; EXTENSORS OF FINGERS                              N     3
                      25301    7                      TENODESIS AT WRIST; EXTENSORS OF FINGERS                              N     3
                      25301    F                      TENODESIS AT WRIST; EXTENSORS OF FINGERS                              N     3
                      25310    2                      TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTE                    N     3
                      25310    7                      TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTE                    N     3
                      25310    8                      TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTE                    N     3
                      25310    F                      TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTE                    N     3
                      25312    2                      TENDON TRANSPLANT OR TRANSFER, FLEXOR OR EXTENSOR,                    N     3
                      25312    7                      TENDON TRANSPLANT OR TRANSFER, FLEXOR OR EXTENSOR,                    N     3
                      25312    F                      TENDON TRANSPLANT OR TRANSFER, FLEXOR OR EXTENSOR,                    N     3
                      25315    2                      FLEXOR ORIGIN SLIDE FOR CEREBRAL PALSY;                               N     3
                      25315    7                      FLEXOR ORIGIN SLIDE FOR CEREBRAL PALSY;                               N     3
                      25315    F                      FLEXOR ORIGIN SLIDE FOR CEREBRAL PALSY;                               N     3
                      25316    2                      FLEXOR ORIGIN SLIDE FOR CEREBRAL PALSY; WITH TENDO                    N     3
                      25316    7                      FLEXOR ORIGIN SLIDE FOR CEREBRAL PALSY; WITH TENDO                    N     3
                      25316    F                      FLEXOR ORIGIN SLIDE FOR CEREBRAL PALSY; WITH TENDO                    N     3
                      25320    2                      CAPSULORRHAPHY OR RECONSTRUCTION, CAPSULECTOMY, WR                    N     3
                      25320    7                      CAPSULORRHAPHY OR RECONSTRUCTION, CAPSULECTOMY, WR                    N     3
                      25320    F                      CAPSULORRHAPHY OR RECONSTRUCTION, CAPSULECTOMY, WR                    N     3
                      25330    2                      ARTHROPLASTY, WRIST;                                                  N     3
                      25330    7                      ARTHROPLASTY, WRIST;                                                  N     3
                      25331    2                      ARTHROPLASTY, WRIST; WITH IMPLANT                                     N     3
                      25331    7                      ARTHROPLASTY, WRIST; WITH IMPLANT                                     N     3
                      25331    8                      ARTHROPLASTY, WRIST; WITH IMPLANT                                     N     3
                      25332    2                      ARTHROPLASTY, WRIST;W OR W/O INTERPOSITION,W OR W/O INTERNAL FX       N     3
                      25332    7                      ARTHROPLASTY, WRIST; PSEUDARTHROSIS TYPE WITH INTE                    N     3
                      25332    8                      ARTHROPLASTY, WRIST;W OR W/O INTERPOSITION,W OR W/O EXT/INT FX        N     3
                      25332    F                      ARTHROPLASTY, WRIST;W OR W/O INTERPOSITION,W OR W/O INTERNAL FX       N     3
                      25335    7                      TRANSPOSITION & REALIGNMENT OF HAND OVER ULNA W OR                    N     3
                      25335    F                      TRANSPOSITION & REALIGNMENT OF HAND OVER ULNA W OR                    N     3
                      25337    2                      RECONSTRUCTION OF UNSTABLE DISTAL ULNA OR DISTAL RADIOULNAR JOINT     N     3
                      25337    7                      ANESTHESIA,RECONSTRUCTION OF UNSTABLE DISTAL ULNA OR DISTAL RADIO     N     3
                      25337    F                      RECONSTRUCTION OF UNSTABLE DISTAL ULNA OR DISTAL RADIOULNAR JOINT     N     3




Updated: 09/22/2006                                                                                                                    Page: 64 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      25350    2                      OSTEOTOMY, RADIUS; DISTAL THIRD                        N     3
                      25350    7                      OSTEOTOMY, RADIUS; DISTAL THIRD                        N     3
                      25350    8                      OSTEOTOMY, RADIUS; DISTAL THIRD                        N     3
                      25350    F                      OSTEOTOMY, RADIUS; DISTAL THIRD                        N     3
                      25355    2                      OSTEOTOMY, RADIUS; MIDDLE OR PROXIMAL THIRD            N     3
                      25355    7                      OSTEOTOMY, RADIUS; MIDDLE OR PROXIMAL THIRD            N     3
                      25355    8                      OSTEOTOMY, RADIUS; MIDDLE OR PROXIMAL THIRD            N     3
                      25355    F                      OSTEOTOMY, RADIUS; MIDDLE OR PROXIMAL THIRD            N     3
                      25360    2                      OSTEOTOMY; ULNA                                        N     3
                      25360    7                      OSTEOTOMY; ULNA                                        N     3
                      25360    8                      OSTEOTOMY; ULNA                                        N     3
                      25360    F                      OSTEOTOMY; ULNA                                        N     3
                      25365    2                      OSTEOTOMY; RADIUS AND ULNA                             N     3
                      25365    7                      OSTEOTOMY; RADIUS AND ULNA                             N     3
                      25365    8                      OSTEOTOMY; RADIUS AND ULNA                             N     3
                      25365    F                      OSTEOTOMY; RADIUS AND ULNA                             N     3
                      25370    2                      MULTIPLE OSTEOTOMIES, WITH REALIGNMENT ON INTRAMED     N     3
                      25370    7                      MULTIPLE OSTEOTOMIES, WITH REALIGNMENT ON INTRAMED     N     3
                      25370    8                      MULTIPLE OSTEOTOMIES, WITH REALIGNMENT ON INTRAMED     N     3
                      25370    F                      MULTIPLE OSTEOTOMIES, WITH REALIGNMENT ON INTRAMED     N     3
                      25375    2                      MULTIPLE OSTEOTOMIES, WITH REALIGNMENT ON INTRAMED     N     3
                      25375    7                      MULTIPLE OSTEOTOMIES, WITH REALIGNMENT ON INTRAMED     N     3
                      25375    8                      MULTIPLE OSTEOTOMIES, WITH REALIGNMENT ON INTRAMED     N     3
                      25375    F                      MULTIPLE OSTEOTOMIES, WITH REALIGNMENT ON INTRAMED     N     3
                      25390    2                      OSTEOPLASTY, RADIUS OR ULNA; SHORTENING                N     3
                      25390    7                      OSTEOPLASTY, RADIUS OR ULNA; SHORTENING                N     3
                      25390    8                      OSTEOPLASTY, RADIUS OR ULNA; SHORTENING                N     3
                      25390    F                      OSTEOPLASTY, RADIUS OR ULNA; SHORTENING                N     3
                      25391    2                      OSTEOPLASTY, RADIUS OR ULNA; LENGTHENING WITH AUTO     N     3
                      25391    7                      OSTEOPLASTY, RADIUS OR ULNA; LENGTHENING WITH AUTO     N     3
                      25391    8                      OSTEOPLASTY, RADIUS OR ULNA; LENGTHENING WITH AUTO     N     3
                      25391    F                      OSTEOPLASTY, RADIUS OR ULNA; LENGTHENING WITH AUTO     N     3
                      25392    2                      OSTEOPLASTY, RADIUS AND ULNA; SHORTENING               N     3
                      25392    7                      OSTEOPLASTY, RADIUS AND ULNA; SHORTENING               N     3
                      25392    F                      OSTEOPLASTY, RADIUS AND ULNA; SHORTENING               N     3
                      25393    2                      OSTEOPLASTY, RADIUS AND ULNA; LENGTHENING WITH AUT     N     3
                      25393    7                      OSTEOPLASTY, RADIUS AND ULNA; LENGTHENING WITH AUT     N     3
                      25393    F                      OSTEOPLASTY, RADIUS AND ULNA; LENGTHENING WITH AUT     N     3
                      25394    2                      OSTEOPLASTY, CARPLA BONE SHORTENING                    N     3
                      25400    2                      REPAIR OF NONUNION OR MALUNION, RADIUS OR ULNA; W/     N     3
                      25400    7                      REPAIR OF NONUNION OR MALUNION, RADIUS OR ULNA; W/     N     3
                      25400    8                      REPAIR OF NONUNION OR MALUNION, RADIUS OR ULNA; W/     N     3
                      25400    F                      REPAIR OF NONUNION OR MALUNION, RADIUS OR ULNA; W/     N     3
                      25405    2                      REPAIR OF NONUNION OR MALUNION, RADIUS OR ULNA; W/     N     3
                      25405    7                      REPAIR OF NONUNION OR MALUNION, RADIUS OR ULNA; W/     N     3
                      25405    8                      REPAIR OF NONUNION OR MALUNION, RADIUS OR ULNA; W/     N     3
                      25405    F                      REPAIR OF NONUNION OR MALUNION, RADIUS OR ULNA; W/     N     3




Updated: 09/22/2006                                                                                                     Page: 65 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      25415    2                      REPAIR OF NONUNION OR MALUNION, RADIUS AND ULNA; W                    N     3
                      25415    7                      REPAIR OF NONUNION OR MALUNION, RADIUS AND ULNA; W                    N     3
                      25415    8                      REPAIR OF NONUNION OR MALUNION, RADIUS AND ULNA; W                    N     3
                      25415    F                      REPAIR OF NONUNION OR MALUNION, RADIUS AND ULNA; W                    N     3
                      25420    2                      REPAIR OF NONUNION OR MALUNION, RADIUS AND ULNA; W                    N     3
                      25420    7                      REPAIR OF NONUNION OR MALUNION, RADIUS AND ULNA; W                    N     3
                      25420    8                      REPAIR OF NONUNION OR MALUNION, RADIUS AND ULNA; W                    N     3
                      25420    F                      REPAIR OF NONUNION OR MALUNION, RADIUS AND ULNA; W                    N     3
                      25425    2                      REPAIR OF DEFECT WITH AUTOGENOUS BONE GRAFT; RADIU                    N     3
                      25425    7                      REPAIR OF DEFECT WITH AUTOGENOUS BONE GRAFT; RADIU                    N     3
                      25425    F                      REPAIR OF DEFECT WITH AUTOGENOUS BONE GRAFT; RADIU                    N     3
                      25426    2                      REPAIR OF DEFECT WITH AUTOGENOUS BONE GRAFT; RADIU                    N     3
                      25426    7                      REPAIR OF DEFECT WITH AUTOGENOUS BONE GRAFT; RADIU                    N     3
                      25426    F                      REPAIR OF DEFECT WITH AUTOGENOUS BONE GRAFT; RADIU                    N     3
                      25430    2                      INSERTION OF VASCULAR DEDICLE INTO CARPAL BONE EG HARII PROCEDURE     N     3
                      25431    2                      REPAIR ON NONUNION OF CARPAL BONE (EXCL CARPARL SCAPHOID (NAVIC)      N     3
                      25440    2                      REPAIR OF NONUNION, SCAPHOID (NAVICULAR) BONE, W O                    N     3
                      25440    7                      REPAIR OF NONUNION, SCAPHOID (NAVICULAR) BONE, W O                    N     3
                      25440    8                      REPAIR OF NONUNION, SCAPHOID (NAVICULAR) BONE, W O                    N     3
                      25440    F                      REPAIR OF NONUNION, SCAPHOID (NAVICULAR) BONE, W O                    N     3
                      25441    2                      ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; DISTAL R                    N     3
                      25441    7                      ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; DISTAL R                    N     3
                      25441    F                      ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; DISTAL R                    N     3
                      25442    2                      ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; DISTAL U                    N     3
                      25442    7                      ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; DISTAL U                    N     3
                      25442    F                      ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; DISTAL U                    N     3
                      25443    2                      ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; SCAPHOID                    N     3
                      25443    7                      ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; SCAPHOID                    N     3
                      25443    F                      ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; SCAPHOID                    N     3
                      25444    2                      ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; LUNATE                      N     3
                      25444    7                      ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; LUNATE                      N     3
                      25444    F                      ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; LUNATE                      N     3
                      25445    2                      ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; TRAPEZIU                    N     3
                      25445    7                      ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; TRAPEZIU                    N     3
                      25445    F                      ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; TRAPEZIU                    N     3
                      25446    2                      ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; DISTAL R                    N     3
                      25446    7                      ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; DISTAL R                    N     3
                      25446    F                      ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; DISTAL R                    N     3
                      25447    2                      INTERPOSITION ARTHROPLASTY: INTERCARP/CARPOMETACAR                    N     3
                      25447    7                      INTERPOSITION ARTHROPLASTY: INTERCARP/CARPOMETACAR                    N     3
                      25447    8                      INTERPOSITION ARTHROPLASTY: INTERCARP/CARPOMETACAR                    N     3
                      25447    F                      INTERPOSITION ARTHROPLASTY: INTERCARP/CARPOMETACAR                    N     3
                      25449    2                      ARTHROPLASTY WITH REMOVAL OF IMPLANT                                  N     3
                      25449    7                      ARTHROPLASTY WITH REMOVAL OF IMPLANT                                  N     3
                      25449    F                      ARTHROPLASTY WITH REMOVAL OF IMPLANT                                  N     3
                      25450    2                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; D                    N     3
                      25450    7                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; D                    N     3




Updated: 09/22/2006                                                                                                                    Page: 66 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                             PA IND PAC
                      25450    8                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; D                  N     3
                      25450    F                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; D                  N     3
                      25455    2                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; D                  N     3
                      25455    7                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; D                  N     3
                      25455    8                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; D                  N     3
                      25455    F                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; D                  N     3
                      25490    7                      PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING                   N     3
                      25490    F                      PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING                   N     3
                      25491    7                      PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING                   N     3
                      25491    F                      PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING                   N     3
                      25492    7                      PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING                   N     3
                      25492    F                      PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING                   N     3
                      25500    2                      TREATMENT OF CLOSED RADIAL SHAFT FRACTURE; WITHOUT                  N     3
                      25500    7                      TREATMENT OF CLOSED RADIAL SHAFT FRACTURE; WITHOUT                  N     3
                      25505    2                      TREATMENT OF CLOSED RADIAL SHAFT FRACTURE; WITH MANIPULATION        N     3
                      25505    7                      TREATMENT OF CLOSED RADIAL SHAFT FRACTURE; WITH MA                  N     3
                      25505    F                      TREATMENT OF CLOSED RADIAL SHAFT FRACTURE; WITH MANIPULATION        N     3
                      25515    2                      OPEN TREATMENT OF CLOSED OR OPEN RADIAL SHAFT FRACTURE              N     3
                      25515    7                      OPEN TREATMENT OF CLOSED OR OPEN RADIAL SHAFT FRAC                  N     3
                      25515    8                      OPEN TREATMENT OF CLOSED OR OPEN RADIAL SHAFT FRAC                  N     3
                      25515    F                      OPEN TREATMENT OF CLOSED OR OPEN RADIAL SHAFT FRACTURE              N     3
                      25520    2                      CLOSED TREATMENT OF RADIAL SHAFT FRACTURE, WITH DISLOCATION         N     3
                      25520    7                      CLOSED TRTMNT OF RADIAL SHAFT FRACTURE WITH DISLOC                  N     3
                      25520    F                      CLOSED TREATMENT OF RADIAL SHAFT FRACTURE, WITH DISLOCATION         N     3
                      25525    2                      OPEN TREATMENT OF RADIAL SHAFT FRACTURE, WITH INTERNAL/EXTERNAL     N     3
                      25525    7                      OPEN TRTMT RAD SHAFT FX W/INTERNAL PERC SKEL                        N     3
                      25525    F                      OPEN TREATMENT OF RADIAL SHAFT FRACTURE, WITH INTERNAL/EXTERNAL     N     3
                      25526    2                      OPEN TREATMENT OF RADIAL SHAFT FRACTURE, WITH INTE                  N     3
                      25526    7                      OPEN TRTMT RAD SHAFT FX W/INTERNAL CART                             N     3
                      25526    F                      OPEN TREATMENT OF RADIAL SHAFT FRACTURE, WITH INTE                  N     3
                      25530    2                      TREATMENT OF CLOSED ULNAR SHAFT FRACTURE; WITHOUT MANIPULATION      N     3
                      25530    7                      TREATMENT OF CLOSED ULNAR SHAFT FRACTURE; WITHOUT                   N     3
                      25535    2                      TREATMENT OF CLOSED ULNAR SHAFT FRACTURE; WITH MANIPULATION         N     3
                      25535    7                      TREATMENT OF CLOSED ULNAR SHAFT FRACTURE; WITH MAN                  N     3
                      25535    F                      TREATMENT OF CLOSED ULNAR SHAFT FRACTURE; WITH MANIPULATION         N     3
                      25545    2                      OPEN TREATMENT OF CLOSED OR OPEN ULNAR SHAFT FRACTURE               N     3
                      25545    7                      OPEN TREATMENT OF CLOSED OR OPEN ULNAR SHAFT FRACT                  N     3
                      25545    8                      OPEN TREATMENT OF CLOSED OR OPEN ULNAR SHAFT FRACT                  N     3
                      25545    F                      OPEN TREATMENT OF CLOSED OR OPEN ULNAR SHAFT FRACTURE               N     3
                      25560    2                      TREATMENT OF CLOSED RADIAL AND ULNAR SHAFT FRACTURE                 N     3
                      25560    7                      TREATMENT OF CLOSED RADIAL AND ULNAR SHAFT FRACTUR                  N     3
                      25565    2                      TRTMT OF CLOSED RADIAL & ULNAR SHAFT FX                             N     3
                      25565    7                      TREATMENT OF CLOSED RADIAL AND ULNAR SHAFT FRACTUR                  N     3
                      25565    8                      TREATMENT OF CLOSED RADIAL AND ULNAR SHAFT FRACTUR                  N     3
                      25565    F                      TRTMT OF CLOSED RADIAL & ULNAR SHAFT FX                             N     3
                      25574    2                      OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES                  N     3
                      25574    7                      OPEN TRTMT OF RADIAL AND ULNAR SHAFT FRACT W/INTER                  N     3




Updated: 09/22/2006                                                                                                                  Page: 67 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      25574    8                      OPEN TRTMT OF RADIAL AND ULNAR SHAFT FRACT W/INTER                    N     3
                      25574    F                      OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES                    N     3
                      25575    2                      OPEN TREATMENT OF CLOSED OR OPEN RADIAL AND ULNAR                     N     3
                      25575    7                      OPEN TREATMENT OF CLOSED OR OPEN RADIAL AND ULNAR                     N     3
                      25575    8                      OPEN TREATMENT OF CLOSED OR OPEN RADIAL AND ULNAR                     N     3
                      25575    F                      OPEN TREATMENT OF CLOSED OR OPEN RADIAL AND ULNAR                     N     3
                      25600    2                      CLOSED TREATMENT OF DISTAL RADIAL FRACTURE LEG (EG COLLES OR SMIT     N     3
                      25600    7                      TRT OF CLOSED DISTAL RADIAL FRAC (COLLES/SMITH) OR                    N     3
                      25605    2                      TRT OF CLOSED DISTAL RADIAL FRAC (COLLES/SMITH) OR                    N     3
                      25605    7                      TRT OF CLOSED DISTAL RADIAL FRAC (COLLES/SMITH) OR                    N     3
                      25605    8                      TRT OF CLOSED DISTAL RADIAL FRAC (COLLES/SMITH) OR                    N     3
                      25605    F                      TRT OF CLOSED DISTAL RADIAL FRAC (COLLES/SMITH) OR                    N     3
                      25611    2                      TRT OF CLOS, COMPLEX, DISTAL RADIAL FRAC W OR W/O                     N     3
                      25611    7                      TRT OF CLOS, COMPLEX, DISTAL RADIAL FRAC W OR W/O                     N     3
                      25611    F                      TRT OF CLOS, COMPLEX, DISTAL RADIAL FRAC W OR W/O                     N     3
                      25620    2                      OPEN TRT OF CLOSED OR OPEN DISTAL RADIAL FRAC, W/                     N     3
                      25620    7                      OPEN TRT OF CLOSED OR OPEN DISTAL RADIAL FRAC, W/                     N     3
                      25620    8                      OPEN TRT OF CLOSED OR OPEN DISTAL RADIAL FRAC, W/                     N     3
                      25620    F                      OPEN TRT OF CLOSED OR OPEN DISTAL RADIAL FRAC, W/                     N     3
                      25622    2                      TREATMENT OF CLOSED CARPAL SCAPHOID (NAVICULAR) FR                    N     3
                      25622    7                      TREATMENT OF CLOSED CARPAL SCAPHOID (NAVICULAR) FR                    N     3
                      25624    2                      TREATMENT OF CLOSED CARPAL SCAPHOID (NAVICULAR) FRACTURE WITH MAN     N     3
                      25624    7                      TREATMENT OF CLOSED CARPAL SCAPHOID (NAVICULAR) FR                    N     3
                      25624    F                      TREATMENT OF CLOSED CARPAL SCAPHOID (NAVICULAR) FRACTURE WITH MAN     N     3
                      25628    2                      OPEN TREATMENT OF CLOSED OR OPEN CARPAL SCAPHOID FRACTURE             N     3
                      25628    7                      OPEN TREATMENT OF CLOSED OR OPEN CARPAL SCAPHOID F                    N     3
                      25628    8                      OPEN TREATMENT OF CLOSED OR OPEN CARPAL SCAPHOID F                    N     3
                      25628    F                      OPEN TREATMENT OF CLOSED OR OPEN CARPAL SCAPHOID FRACTURE             N     3
                      25630    2                      TREATMENT OF CLOSED CARPAL BONE FRACTURE (EXCLUDING CARPAL SCAPHO     N     3
                      25630    7                      TREATMENT OF CLOSED CARPAL BONE FRACTURE (EXCLUDIN                    N     3
                      25635    2                      TREATMENT OF CLOSED CARPAL BONE FRACTURE WITH MANIPULATION EACH B     N     3
                      25635    7                      TREATMENT OF CLOSED CARPAL BONE FRACTURE (EXCLUDIN                    N     3
                      25635    F                      TREATMENT OF CLOSED CARPAL BONE FRACTURE WITH MANIPULATION EACH B     N     3
                      25645    2                      OPEN TREATMENT OF CLOSED OR OPEN CARPAL BONE FRACTURE EXCLUDING       N     3
                      25645    7                      OPEN TREATMENT OF CLOSED OR OPEN CARPAL BONE FRAC                     N     3
                      25645    8                      OPEN TREATMENT OF CLOSED OR OPEN CARPAL BONE FRAC                     N     3
                      25645    F                      OPEN TREATMENT OF CLOSED OR OPEN CARPAL BONE FRACTURE EXCLUDING       N     3
                      25650    2                      TREATMENT OF CLOSED ULNAR STYLOID FRACTURE                            N     3
                      25650    7                      TREATMENT OF CLOSED ULNAR STYLOID FRACTURE                            N     3
                      25651    2                      PERCUTANEOUS SKELETAL FIXATION OF ULNAR STYLOID FRACTURE              N     3
                      25660    2                      TREATMENT OF CLOSED RADIOCARPAL OR INTERCARPAL DISLOCATION            N     3
                      25660    7                      TREATMENT OF CLOSED RADIOCARPAL OR INTERCARPAL DIS                    N     3
                      25660    F                      TREATMENT OF CLOSED RADIOCARPAL OR INTERCARPAL DISLOCATION            N     3
                      25670    7                      OPEN TREATMENT OF CLOSED OR OPEN RADIOCARPAL OR IN                    N     3
                      25670    F                      OPEN TREATMENT OF CLOSED OR OPEN RADIOCARPAL OR INTERCARPAL           N     3
                      25675    2                      TREATMENT OF CLOSED DISTAL RADIOULNAR DISLOCATION                     N     3
                      25675    7                      TREATMENT OF CLOSED DISTAL RADIOULNAR DISLOCATION                     N     3




Updated: 09/22/2006                                                                                                                    Page: 68 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      25675    F                      TREATMENT OF CLOSED DISTAL RADIOULNAR DISLOCATION                     N     3
                      25676    2                      OPEN TREATMENT OF CLOSED OR OPEN DISTAL RADIOULNAR DISLOCATION        N     3
                      25676    7                      OPEN TREATMENT OF CLOSED OR OPEN DISTAL RADIOULNAR                    N     3
                      25676    8                      OPEN TREATMENT OF CLOSED OR OPEN DISTAL RADIOULNAR                    N     3
                      25676    F                      OPEN TREATMENT OF CLOSED OR OPEN DISTAL RADIOULNAR DISLOCATION        N     3
                      25680    2                      TREATMENT OF CLOSED TRANS-SCAPHOPERILUNAR TYPE OF                     N     3
                      25680    7                      TREATMENT OF CLOSED TRANS-SCAPHOPERILUNAR TYPE OF                     N     3
                      25680    F                      TREATMENT OF CLOSED TRANS-SCAPHOPERILUNAR TYPE OF                     N     3
                      25685    2                      OPEN TREATMENT OF CLOSED OR OPEN TRANS-SCAPHOPERIL                    N     3
                      25685    7                      OPEN TREATMENT OF CLOSED OR OPEN TRANS-SCAPHOPERIL                    N     3
                      25685    8                      OPEN TREATMENT OF CLOSED OR OPEN TRANS-SCAPHOPERIL                    N     3
                      25685    F                      OPEN TREATMENT OF CLOSED OR OPEN TRANS-SCAPHOPERIL                    N     3
                      25690    2                      TREATMENT OF LUNATE DISLOCATION, WITH MANIPULATION                    N     3
                      25690    7                      TREATMENT OF LUNATE DISLOCATION, WITH MANIPULATION                    N     3
                      25690    F                      TREATMENT OF LUNATE DISLOCATION, WITH MANIPULATION                    N     3
                      25695    2                      OPEN TREATMENT OF LUNATE DISLOCATION                                  N     3
                      25695    7                      OPEN TREATMENT OF LUNATE DISLOCATION                                  N     3
                      25695    F                      OPEN TREATMENT OF LUNATE DISLOCATION                                  N     3
                      25700    2                      MANIPULATION OF JOINT UNDER GENERAL ANESTHESIA                        N     3
                      25700    7                      MANIPULATION OF JOINT UNDER GENERAL ANESTHESIA                        N     3
                      25800    2                      ARTHRODESIS, WRIST JOINT; WITHOUT BONE GRAFT                          N     3
                      25800    7                      ARTHRODESIS, WRIST JOINT; WITHOUT BONE GRAFT                          N     3
                      25800    F                      ARTHRODESIS, WRIST JOINT; WITHOUT BONE GRAFT                          N     3
                      25805    2                      ARTHRODESIS, WRIST JOINT; WITH SLIDING GRAFT                          N     3
                      25805    7                      ARTHRODESIS, WRIST JOINT; WITH SLIDING GRAFT                          N     3
                      25805    8                      ARTHRODESIS, WRIST JOINT; WITH SLIDING GRAFT                          N     3
                      25805    F                      ARTHRODESIS, WRIST JOINT; WITH SLIDING GRAFT                          N     3
                      25810    2                      ARTHRODESIS, WRIST JOINT; W/ ILIAC OR OTHER AUTOGE                    N     3
                      25810    7                      ARTHRODESIS, WRIST JOINT; W/ ILIAC OR OTHER AUTOGE                    N     3
                      25810    8                      ARTHRODESIS, WRIST JOINT; W/ ILIAC OR OTHER AUTOGE                    N     3
                      25810    F                      ARTHRODESIS, WRIST JOINT; W/ ILIAC OR OTHER AUTOGE                    N     3
                      25811    7                      ANESTHESIA,APPLICATION OF PROSTHETIC DEVICE TO VERTEBRAL DEFECT       N     3
                      25820    7                      INTERCARPAL FUSION                                                    N     3
                      25820    F                      INTERCARPAL FUSION                                                    N     3
                      25825    2                      INTERCARPAL FUSION W GRFT                                             N     3
                      25825    7                      INTERCARPAL FUSION W GRFT                                             N     3
                      25825    8                      INTERCARPAL FUSION;W/OUT BONE GRAFT                                   N     3
                      25825    F                      INTERCARPAL FUSION W GRFT                                             N     3
                      25830    2                      DISTAL RADIOULNAR JOINT ARTHRODESIS & SEGMENTAL RESECTION OF ULNA     N     3
                      25830    F                      DISTAL RADIOULNAR JOINT ARTHRODESIS & SEGMENTAL RESECTION OF ULNA     N     3
                      25900    2                      AMPUTATION, FOREARM, THROUGH RADIUS AND ULNA;                         N     3
                      25900    7                      AMPUTATION, FOREARM, THROUGH RADIUS AND ULNA;                         N     3
                      25900    8                      AMPUTATION, FOREARM, THROUGH RADIUS AND ULNA;                         N     3
                      25905    2                      AMPUTATION, FOREARM, THROUGH RADIUS AND ULNA; OPEN                    N     3
                      25905    7                      AMPUTATION, FOREARM, THROUGH RADIUS AND ULNA; OPEN                    N     3
                      25905    8                      AMPUTATION, FOREARM, THROUGH RADIUS AND ULNA; OPEN                    N     3
                      25907    2                      AMPUTATION, FOREARM, THROUGH RADIUS AND ULNA; SECO                    N     3




Updated: 09/22/2006                                                                                                                    Page: 69 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      25907    7                      AMPUTATION, FOREARM, THROUGH RADIUS AND ULNA; SECO     N     3
                      25907    F                      AMPUTATION, FOREARM, THROUGH RADIUS AND ULNA; SECO     N     3
                      25909    2                      AMPUTATION, FOREARM, THROUGH RADIUS AND ULNA; REAM     N     3
                      25909    7                      AMPUTATION, FOREARM, THROUGH RADIUS AND ULNA; REAM     N     3
                      25915    2                      KRUKENBERG PROCEDURE                                   N     3
                      25915    7                      KRUKENBERG PROCEDURE                                   N     3
                      25920    2                      DISARTICULATION THROUGH WRIST;                         N     3
                      25920    7                      DISARTICULATION THROUGH WRIST;                         N     3
                      25920    8                      DISARTICULATION THROUGH WRIST;                         N     3
                      25922    2                      DISARTICULATION THROUGH WRIST; SECONDARY CLOSURE O     N     3
                      25922    7                      DISARTICULATION THROUGH WRIST; SECONDARY CLOSURE O     N     3
                      25922    F                      DISARTICULATION THROUGH WRIST; SECONDARY CLOSURE O     N     3
                      25924    2                      DISARTICULATION THROUGH WRIST; REAMPUTATION            N     3
                      25924    7                      DISARTICULATION THROUGH WRIST; REAMPUTATION            N     3
                      25927    2                      TRANSMETACARPAL AMPUTATION;                            N     3
                      25927    7                      TRANSMETACARPAL AMPUTATION;                            N     3
                      25929    2                      TRANSMETACARPAL AMPUTATION; SECONDARY CLOSURE OR S     N     3
                      25929    7                      TRANSMETACARPAL AMPUTATION; SECONDARY CLOSURE OR S     N     3
                      25929    F                      TRANSMETACARPAL AMPUTATION; SECONDARY CLOSURE OR S     N     3
                      25931    2                      TRANSMETACARPAL AMPUTATION; REAMPUTATION               N     3
                      25931    7                      TRANSMETACARPAL AMPUTATION; REAMPUTATION               N     3
                      25999    7                      UNLISTED PROCEDURE, FOREARM OR WRIST                   N     3
                      26010    2                      DRAINAGE OF FINGER ABSCESS; SIMPLE                     N     3
                      26010    7                      DRAINAGE OF FINGER ABSCESS; SIMPLE                     N     3
                      26011    2                      DRAINAGE OF FINGER ABSCESS; COMPLICATED (EG, FELON     N     3
                      26011    7                      DRAINAGE OF FINGER ABSCESS; COMPLICATED (EG, FELON     N     3
                      26011    8                      DRAINAGE OF FINGER ABSCESS; COMPLICATED (EG, FELON     N     3
                      26011    F                      DRAINAGE OF FINGER ABSCESS; COMPLICATED (EG, FELON     N     3
                      26020    2                      DRAINAGE OF TENDON SHEATH, ONE DIGIT AND/OR PALM       N     3
                      26020    7                      DRAINAGE OF TENDON SHEATH, ONE DIGIT AND/OR PALM       N     3
                      26020    F                      DRAINAGE OF TENDON SHEATH, ONE DIGIT AND/OR PALM       N     3
                      26025    2                      DRAINAGE OF PALMAR BURSA; SINGLE, ULNAR OR RADIAL      N     3
                      26025    7                      DRAINAGE OF PALMAR BURSA; SINGLE, ULNAR OR RADIAL      N     3
                      26025    F                      DRAINAGE OF PALMAR BURSA; SINGLE, ULNAR OR RADIAL      N     3
                      26030    2                      DRAINAGE OF PALMAR BURSA; MULTIPLE OR COMPLICATED      N     3
                      26030    7                      DRAINAGE OF PALMAR BURSA; MULTIPLE OR COMPLICATED      N     3
                      26030    F                      DRAINAGE OF PALMAR BURSA; MULTIPLE OR COMPLICATED      N     3
                      26032    2                      DRAINAGE OF PALMAR BURSA; WITH SUCTION IRRIGATION      N     3
                      26034    2                      INCISION, DEEP, WITH OPENING OF CORTEX FOR OSTEOMY     N     3
                      26034    7                      INCISION, DEEP, WITH OPENING OF CORTEX FOR OSTEOMY     N     3
                      26034    8                      INCISION,DEEP, WITH OPENING OF CORTEX FOR OSTEOMY      N     3
                      26034    F                      INCISION, DEEP, WITH OPENING OF CORTEX FOR OSTEOMY     N     3
                      26035    2                      DECOMPRESSION FINGERS AND/OR HAND, INJECTION INJUR     N     3
                      26035    7                      DECOMPRESSION FINGERS AND/OR HAND, INJECTION INJUR     N     3
                      26037    2                      DECOMPRESSIVE FASCIOTOMY, HAND (EXCLUDES 26035)        N     3
                      26037    7                      DECOMPRESSIVE FASCIOTOMY, HAND (EXCLUDES 26035)        N     3
                      26040    2                      FASCIOTOMY, PALMAR, FOR DUPUYTREN'S CONTRACTURE; C     N     3




Updated: 09/22/2006                                                                                                     Page: 70 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      26040    7                      FASCIOTOMY, PALMAR, FOR DUPUYTREN'S CONTRACTURE; C                    N     3
                      26040    F                      FASCIOTOMY, PALMAR, FOR DUPUYTREN'S CONTRACTURE; C                    N     3
                      26045    2                      FASCIOTOMY, PALMAR, FOR DUPUYTREN'S CONTRACTURE; O                    N     3
                      26045    7                      FASCIOTOMY, PALMAR, FOR DUPUYTREN'S CONTRACTURE; O                    N     3
                      26045    F                      FASCIOTOMY, PALMAR, FOR DUPUYTREN'S CONTRACTURE; O                    N     3
                      26055    2                      TENDON SHEATH INCISION FOR TRIGGER FINGER                             N     3
                      26055    7                      TENDON SHEATH INCISION FOR TRIGGER FINGER                             N     3
                      26055    8                      TENDON SHEATH INCISION FOR TRIGGER FINGER                             N     3
                      26055    F                      TENDON SHEATH INCISION FOR TRIGGER FINGER                             N     3
                      26060    2                      TENOTOMY, SUBCUTANEOUS, SINGLE, EACH DIGIT                            N     3
                      26060    7                      TENOTOMY, SUBCUTANEOUS, SINGLE, EACH DIGIT                            N     3
                      26060    F                      TENOTOMY, SUBCUTANEOUS, SINGLE, EACH DIGIT                            N     3
                      26070    2                      ARTHROTOMY WITH EXPLOR, DRAIN OR REMOVAL OF LOOSE                     N     3
                      26070    7                      ARTHROTOMY WITH EXPLOR, DRAIN OR REMOVAL OF LOOSE                     N     3
                      26070    F                      ARTHROTOMY WITH EXPLOR, DRAIN OR REMOVAL OF LOOSE                     N     3
                      26075    2                      ARTHROTOMY W/EXPLOR, DRAIN OR REMOV OF LOOSE OR FO                    N     3
                      26075    7                      ARTHROTOMY W/EXPLOR, DRAIN OR REMOV OF LOOSE OR FO                    N     3
                      26075    F                      ARTHROTOMY W/EXPLOR, DRAIN OR REMOV OF LOOSE OR FO                    N     3
                      26080    2                      ARTHROTOMY W/EXPLOR, DRAIN OR REMOV OF LOOSE OR FO                    N     3
                      26080    7                      ARTHROTOMY W/EXPLOR, DRAIN OR REMOV OF LOOSE OR FO                    N     3
                      26080    F                      ARTHROTOMY W/EXPLOR, DRAIN OR REMOV OF LOOSE OR FO                    N     3
                      26100    2                      ARTHROTOMY FOR SYNOVIAL BIOPSY; CARPOMETACARPAL JO                    N     3
                      26100    7                      ARTHROTOMY FOR SYNOVIAL BIOPSY; CARPOMETACARPAL JO                    N     3
                      26100    F                      ARTHROTOMY FOR SYNOVIAL BIOPSY; CARPOMETACARPAL JO                    N     3
                      26105    2                      ARTHROTOMY FOR SYNOVIAL BIOPSY; METACARPOPHALANGEA                    N     3
                      26105    7                      ARTHROTOMY FOR SYNOVIAL BIOPSY; METACARPOPHALANGEA                    N     3
                      26105    F                      ARTHROTOMY FOR SYNOVIAL BIOPSY; METACARPOPHALANGEA                    N     3
                      26110    2                      ARTHROTOMY FOR SYNOVIAL BIOPSY; INTERPHALANGEAL JO                    N     3
                      26110    7                      ARTHROTOMY FOR SYNOVIAL BIOPSY; INTERPHALANGEAL JO                    N     3
                      26110    F                      ARTHROTOMY FOR SYNOVIAL BIOPSY; INTERPHALANGEAL JO                    N     3
                      26115    2                      EXCISION OF BENIGN TUMOR; SUBCUTANEOUS                                N     3
                      26115    F                      EXCISION OF BENIGN TUMOR; SUBCUTANEOUS                                N     3
                      26116    2                      .XCISION OF BENIGN TUMOR; DEEP, SUBFASCIAL, INTRAM                    N     3
                      26116    7                      EXCISION OF BENIGN TUMOR; DEEP, SUBFASCIAL, INTRAM                    N     3
                      26116    F                      .XCISION OF BENIGN TUMOR; DEEP, SUBFASCIAL, INTRAM                    N     3
                      26117    7                      RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM                    N     3
                      26117    F                      RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM                    N     3
                      26121    2                      FASCIECTOMY, PALM ONLY, W OR W/O Z/PLASTY, OTHER TISSUE REARRANGE     N     3
                      26121    7                      FASCIECTOMY, PALMAR, WITH OR WITHOUT Z-PLASTY, OTH                    N     3
                      26121    8                      FASCIECTOMY, PALMAR, WITH OR WITHOUT Z-PLASTY, OTH                    N     3
                      26121    F                      FASCIECTOMY, PALM ONLY, W OR W/O Z/PLASTY, OTHER TISSUE REARRANGE     N     3
                      26123    2                      FASCIECTOMY, PALMAR, WITH OR WITHOUT Z-PLASTY, OTH                    N     3
                      26123    7                      FASCIECTOMY, PALMAR, WITH OR WITHOUT Z-PLASTY, OTH                    N     3
                      26123    F                      FASCIECTOMY, PALMAR, WITH OR WITHOUT Z-PLASTY, OTH                    N     3
                      26125    2                      FASCIECTOMY, PALMAR, WITH OR WITHOUT Z-PLASTY, OTH                    N     3
                      26125    7                      FASCIECTOMY, PALMAR, WITH OR WITHOUT Z-PLASTY, OTH                    N     3
                      26125    F                      FASCIECTOMY, PALMAR, WITH OR WITHOUT Z-PLASTY, OTH                    N     3




Updated: 09/22/2006                                                                                                                    Page: 71 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                  PA IND PAC
                      26130    2                      SYNOVECTOMY, CARPOMETACARPAL JOINT                       N     3
                      26130    7                      SYNOVECTOMY, CARPOMETACARPAL JOINT                       N     3
                      26130    F                      SYNOVECTOMY, CARPOMETACARPAL JOINT                       N     3
                      26135    2                      SYNOVECTOMY METACARPOPHALANGEAL JOINT INCLUD INTRI       N     3
                      26135    7                      SYNOVECTOMY METACARPOPHALANGEAL JOINT INCLUD INTRI       N     3
                      26135    F                      SYNOVECTOMY METACARPOPHALANGEAL JOINT INCLUD INTRI       N     3
                      26140    2                      SYNOVECTOMY PROXIMAL INTERPHALANGEAL JOINT, INCLUD       N     3
                      26140    7                      SYNOVECTOMY PROXIMAL INTERPHALANGEAL JOINT, INCLUD       N     3
                      26140    F                      SYNOVECTOMY PROXIMAL INTERPHALANGEAL JOINT, INCLUD       N     3
                      26145    2                      SYNOVECTOMY TENDON SHEATH, RADICAL (TENOSYNOVECTOM       N     3
                      26145    7                      SYNOVECTOMY TENDON SHEATH, RADICAL (TENOSYNOVECTOM       N     3
                      26145    8                      SYNOVECTOMY TENDON SHEATH, RADICAL (TENOSYNOVECTOM       N     3
                      26145    F                      SYNOVECTOMY TENDON SHEATH, RADICAL (TENOSYNOVECTOM       N     3
                      26160    2                      EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG       N     3
                      26160    7                      EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG       N     3
                      26160    F                      EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG       N     3
                      26170    2                      EXCISION OF TENDON, PALM, FLEXOR, SINGLE (SEPARATE       N     3
                      26170    7                      EXCISION OF TENDON, PALM, FLEXOR, SINGLE (SEPARATE       N     3
                      26170    F                      EXCISION OF TENDON, PALM, FLEXOR, SINGLE (SEPARATE       N     3
                      26180    2                      EXCISION OF TENDON, FINGER, FLEXOR (SEPARATE PROC)       N     3
                      26180    7                      EXCISION OF TENDON, FINGER, FLEXOR (SEPARATE PROC)       N     3
                      26180    F                      EXCISION OF TENDON, FINGER, FLEXOR (SEPARATE PROC)       N     3
                      26185    2                      SESAMOIDECTOMY,THUMB OR FINGER (SEPARATE PROCEDURE)      N     3
                      26185    7                      SESAMOIDECTOMY,THUMB OR FINGER (SEPARATE PROCEDURE)      N     3
                      26185    8                      SESAMOIDECTOMY, THUMB OR FINGER (SEPARATE PROCEDURE)     N     3
                      26185    F                      SESAMOIDECTOMY,THUMB OR FINGER (SEPARATE PROCEDURE)      N     3
                      26200    2                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR       N     3
                      26200    7                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR       N     3
                      26200    F                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR       N     3
                      26205    2                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR       N     3
                      26205    7                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR       N     3
                      26205    F                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR       N     3
                      26206    2                      EXCIS OR CURETT OF BONE CYST OR BENIGN TUMOR OF ME       N     3
                      26206    7                      EXCIS OR CURETT OF BONE CYST OR BENIGN TUMOR OF ME       N     3
                      26210    2                      EXCIS OR CURETT OF BONE CYST OR BENIGN TUMOR OF PR       N     3
                      26210    7                      EXCIS OR CURETT OF BONE CYST OR BENIGN TUMOR OF PR       N     3
                      26210    F                      EXCIS OR CURETT OF BONE CYST OR BENIGN TUMOR OF PR       N     3
                      26215    2                      EXCIS OR CURETT OF BONE CYST OR BENIGN TUMOR OF PR       N     3
                      26215    7                      EXCIS OR CURETT OF BONE CYST OR BENIGN TUMOR OF PR       N     3
                      26215    F                      EXCIS OR CURETT OF BONE CYST OR BENIGN TUMOR OF PR       N     3
                      26216    2                      EXCIS OR CURETT OF BONE CYST OR BENIGN TUMOR OF PR       N     3
                      26216    7                      EXCIS OR CURETT OF BONE CYST OR BENIGN TUMOR OF PR       N     3
                      26230    2                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA       N     3
                      26230    7                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA       N     3
                      26230    F                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA       N     3
                      26235    2                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA       N     3
                      26235    7                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA       N     3




Updated: 09/22/2006                                                                                                       Page: 72 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                     PA IND PAC
                      26235    F                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA          N     3
                      26236    2                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA          N     3
                      26236    7                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA          N     3
                      26236    F                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA          N     3
                      26250    2                      RADICAL RESECTION (OSTECTOMY) FOR TUMOR, METACARPA          N     3
                      26250    7                      RADICAL RESECTION (OSTECTOMY) FOR TUMOR, METACARPA          N     3
                      26250    F                      RADICAL RESECTION (OSTECTOMY) FOR TUMOR, METACARPA          N     3
                      26255    2                      RADICAL RESECTION (OSTECTOMY) FOR TUMOR, METACARPA          N     3
                      26255    7                      RADICAL RESECTION (OSTECTOMY) FOR TUMOR, METACARPA          N     3
                      26255    F                      RADICAL RESECTION (OSTECTOMY) FOR TUMOR, METACARPA          N     3
                      26260    2                      RADICAL RESECTION (OSTECTOMY) FOR TUMOR, PROXIMAL           N     3
                      26260    7                      RADICAL RESECTION (OSTECTOMY) FOR TUMOR, PROXIMAL           N     3
                      26260    F                      RADICAL RESECTION (OSTECTOMY) FOR TUMOR, PROXIMAL           N     3
                      26261    2                      RADICAL RESECTION (OSTECTOMY) FOR TUMOR, PROXIMAL           N     3
                      26261    7                      RADICAL RESECTION (OSTECTOMY) FOR TUMOR, PROXIMAL           N     3
                      26261    8                      RADICAL RESECTION (OSTECTOMY) FOR TUMOR, PROXIMAL           N     3
                      26261    F                      RADICAL RESECTION (OSTECTOMY) FOR TUMOR, PROXIMAL           N     3
                      26262    2                      RADICAL RESECTION (OSTECTOMY) FOR TUMOR, DISTAL PH          N     3
                      26262    7                      RADICAL RESECTION (OSTECTOMY) FOR TUMOR, DISTAL PH          N     3
                      26262    F                      RADICAL RESECTION (OSTECTOMY) FOR TUMOR, DISTAL PH          N     3
                      26320    2                      REMOVAL OF IMPLANT FROM FINGER OR HAND                      N     3
                      26320    7                      REMOVAL OF IMPLANT FROM FINGER OR HAND                      N     3
                      26320    F                      REMOVAL OF IMPLANT FROM FINGER OR HAND                      N     3
                      26340    2                      MANIPULATION, FINGER JOINT, UNDER ANESTHESIA EACH JOINT     N     3
                      26350    2                      FLEXOR TENDON REPAIR OR ADVANCE, SINGL, NOT IN NO           N     3
                      26350    7                      FLEXOR TENDON REPAIR OR ADVANCE, SINGL, NOT IN NO           N     3
                      26350    8                      FLEXOR TENDON REPAIR OR ADVANCE, SINGL, NOT IN NO           N     3
                      26350    F                      FLEXOR TENDON REPAIR OR ADVANCE, SINGL, NOT IN NO           N     3
                      26352    2                      FLEXOR TENDON REPAIR OR ADVANCE, SINGL, NOT IN NO           N     3
                      26352    7                      FLEXOR TENDON REPAIR OR ADVANCE, SINGL, NOT IN NO           N     3
                      26352    F                      FLEXOR TENDON REPAIR OR ADVANCE, SINGL, NOT IN NO           N     3
                      26356    2                      FLEXOR TENDON REPAIR OR ADVANCE, SINGL, IN NO MAN'          N     3
                      26356    7                      FLEXOR TENDON REPAIR OR ADVANCE, SINGL, IN NO MAN'          N     3
                      26356    8                      FLEXOR TENDON REPAIR OR ADUANCE, SINGL, IN HO MAN'          N     3
                      26356    F                      FLEXOR TENDON REPAIR OR ADVANCE, SINGL, IN NO MAN'          N     3
                      26357    7                      FLEXOR TENDON REPAIR OR ADVANCEMENT, SINGLE, IN             N     3
                      26357    F                      FLEXOR TENDON REPAIR OR ADVANCEMENT, SINGLE, IN             N     3
                      26358    2                      FLEXOR TENDON REPAIR OR ADVANCE, SINGL, IN NO MAN'          N     3
                      26358    7                      FLEXOR TENDON REPAIR OR ADVANCE, SINGL, IN NO MAN'          N     3
                      26358    F                      FLEXOR TENDON REPAIR OR ADVANCE, SINGL, IN NO MAN'          N     3
                      26370    2                      PROFUNDUS TENDON REPAIR OR ADVANCEMENT, WITH INTAC          N     3
                      26370    7                      PROFUNDUS TENDON REPAIR OR ADVANCEMENT, WITH INTAC          N     3
                      26370    8                      PROFUNDUS TENDON REPAIR OR ADVANCEMENT, WITH INTAC          N     3
                      26370    F                      PROFUNDUS TENDON REPAIR OR ADVANCEMENT, WITH INTAC          N     3
                      26372    2                      PROFUNDUS TENDON REPAIR OR ADVANCEMENT, WITH INTAC          N     3
                      26372    7                      PROFUNDUS TENDON REPAIR OR ADVANCEMENT, WITH INTAC          N     3
                      26372    F                      PROFUNDUS TENDON REPAIR OR ADVANCEMENT, WITH INTAC          N     3




Updated: 09/22/2006                                                                                                          Page: 73 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      26373    2                      PROFUNDUS TENDON REPAIR OR ADVANCEMENT, WITH INTAC     N     3
                      26373    7                      PROFUNDUS TENDON REPAIR OR ADVANCEMENT, WITH INTAC     N     3
                      26373    F                      PROFUNDUS TENDON REPAIR OR ADVANCEMENT, WITH INTAC     N     3
                      26390    2                      FLEXOR TENDON EXCISION, IMPLANTATION OF PLASTIC TU     N     3
                      26390    7                      FLEXOR TENDON EXCISION, IMPLANTATION OF PLASTIC TU     N     3
                      26390    F                      FLEXOR TENDON EXCISION, IMPLANTATION OF PLASTIC TU     N     3
                      26392    2                      REMOVAL OF TUBE OR ROD AND INSERTION OF TENDON GRA     N     3
                      26392    7                      REMOVAL OF TUBE OR ROD AND INSERTION OF TENDON GRA     N     3
                      26392    F                      REMOVAL OF TUBE OR ROD AND INSERTION OF TENDON GRA     N     3
                      26410    2                      EXTENSOR TENDON REPAIR, DORSUM OF HAND, SINGLE, PR     N     3
                      26410    7                      EXTENSOR TENDON REPAIR, DORSUM OF HAND, SINGLE, PR     N     3
                      26410    F                      EXTENSOR TENDON REPAIR, DORSUM OF HAND, SINGLE, PR     N     3
                      26412    2                      EXTENSOR TENDON REPAIR, DORSUM OF HAND, SINGLE, PR     N     3
                      26412    7                      EXTENSOR TENDON REPAIR, DORSUM OF HAND, SINGLE, PR     N     3
                      26412    F                      EXTENSOR TENDON REPAIR, DORSUM OF HAND, SINGLE, PR     N     3
                      26415    2                      EXTENSOR TENDON EXCISION, IMPLANTATION OF PLASTIC      N     3
                      26415    7                      EXTENSOR TENDON EXCISION, IMPLANTATION OF PLASTIC      N     3
                      26415    F                      EXTENSOR TENDON EXCISION, IMPLANTATION OF PLASTIC      N     3
                      26416    2                      REMOVAL OF TUBE OR ROD AND INSERTION OF EXTENSOR T     N     3
                      26416    7                      REMOVAL OF TUBE OR ROD AND INSERTION OF EXTENSOR T     N     3
                      26416    F                      REMOVAL OF TUBE OR ROD AND INSERTION OF EXTENSOR T     N     3
                      26418    2                      EXTENSOR TENDON REPAIR, DORSUM OF FINGER, SINGLE,      N     3
                      26418    7                      EXTENSOR TENDON REPAIR, DORSUM OF FINGER, SINGLE,      N     3
                      26418    F                      EXTENSOR TENDON REPAIR, DORSUM OF FINGER, SINGLE,      N     3
                      26420    2                      EXTENSOR TENDON REPAIR, DORSUM OF FINGER, SINGLE,      N     3
                      26420    7                      EXTENSOR TENDON REPAIR, DORSUM OF FINGER, SINGLE,      N     3
                      26420    F                      EXTENSOR TENDON REPAIR, DORSUM OF FINGER, SINGLE,      N     3
                      26426    2                      EXTENSOR TENDON REPAIR, CENTRAL SLIP REPAIR, SECON     N     3
                      26426    7                      EXTENSOR TENDON REPAIR, CENTRAL SLIP REPAIR, SECON     N     3
                      26426    F                      EXTENSOR TENDON REPAIR, CENTRAL SLIP REPAIR, SECON     N     3
                      26428    2                      EXTENSOR TENDON REPAIR, CENTRAL SLIP REPAIR, SECON     N     3
                      26428    7                      EXTENSOR TENDON REPAIR, CENTRAL SLIP REPAIR, SECON     N     3
                      26428    F                      EXTENSOR TENDON REPAIR, CENTRAL SLIP REPAIR, SECON     N     3
                      26432    2                      EXTENSOR TENDON REPAIR, DISTAL INSERTION (''MALLET     N     3
                      26432    7                      EXTENSOR TENDON REPAIR, DISTAL INSERTION (''MALLET     N     3
                      26432    F                      EXTENSOR TENDON REPAIR, DISTAL INSERTION (''MALLET     N     3
                      26433    2                      EXTENSOR TENDON REPAIR, OPEN, PRIMARY OR SECONDARY     N     3
                      26433    7                      EXTENSOR TENDON REPAIR, OPEN, PRIMARY OR SECONDARY     N     3
                      26433    F                      EXTENSOR TENDON REPAIR, OPEN, PRIMARY OR SECONDARY     N     3
                      26434    2                      EXTENSOR TENDON REPAIR, OPEN, PRIMARY OR SECONDARY     N     3
                      26434    7                      EXTENSOR TENDON REPAIR, OPEN, PRIMARY OR SECONDARY     N     3
                      26434    F                      EXTENSOR TENDON REPAIR, OPEN, PRIMARY OR SECONDARY     N     3
                      26437    2                      EXTENSOR TENDON REALIGNMENT, HAND                      N     3
                      26437    7                      EXTENSOR TENDON REALIGNMENT, HAND                      N     3
                      26437    F                      EXTENSOR TENDON REALIGNMENT, HAND                      N     3
                      26440    2                      TENOLYSIS, SIMPLE, FLEXOR TENDON; PALM OR FINGER,      N     3
                      26440    7                      TENOLYSIS, SIMPLE, FLEXOR TENDON; PALM OR FINGER,      N     3




Updated: 09/22/2006                                                                                                     Page: 74 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      26440    F                      TENOLYSIS, SIMPLE, FLEXOR TENDON; PALM OR FINGER,      N     3
                      26442    2                      TENOLYSIS, SIMPLE, FLEXOR TENDON; PALM AND FINGER,     N     3
                      26442    7                      TENOLYSIS, SIMPLE, FLEXOR TENDON; PALM AND FINGER,     N     3
                      26442    F                      TENOLYSIS, SIMPLE, FLEXOR TENDON; PALM AND FINGER,     N     3
                      26445    2                      TENOLYSIS, EXTENSOR TENDON, DORSUM OF HAND OR FING     N     3
                      26445    7                      TENOLYSIS, EXTENSOR TENDON, DORSUM OF HAND OR FING     N     3
                      26445    F                      TENOLYSIS, EXTENSOR TENDON, DORSUM OF HAND OR FING     N     3
                      26449    2                      TENOLYSIS, COMPLEX, EXTENSOR TENDON, DORSUM OF HAN     N     3
                      26449    7                      TENOLYSIS, COMPLEX, EXTENSOR TENDON, DORSUM OF HAN     N     3
                      26449    F                      TENOLYSIS, COMPLEX, EXTENSOR TENDON, DORSUM OF HAN     N     3
                      26450    2                      TENOTOMY, FLEXOR, SINGLE, PALM, OPEN, EACH             N     3
                      26450    7                      TENOTOMY, FLEXOR, SINGLE, PALM, OPEN, EACH             N     3
                      26450    F                      TENOTOMY, FLEXOR, SINGLE, PALM, OPEN, EACH             N     3
                      26455    2                      TENOTOMY, FLEXOR, SINGLE, FINGER, OPEN, EACH           N     3
                      26455    7                      TENOTOMY, FLEXOR, SINGLE, FINGER, OPEN, EACH           N     3
                      26455    F                      TENOTOMY, FLEXOR, SINGLE, FINGER, OPEN, EACH           N     3
                      26460    2                      TENOTOMY, EXTENSOR, HAND OR FINGER, SINGLE, EACH       N     3
                      26460    7                      TENOTOMY, EXTENSOR, HAND OR FINGER, SINGLE, EACH       N     3
                      26460    8                      TENOTOMY, EXTENSOR, HAND OR FINGER, SINGLE, EACH       N     3
                      26460    F                      TENOTOMY, EXTENSOR, HAND OR FINGER, SINGLE, EACH       N     3
                      26471    2                      TENODESIS; FOR PROXIMAL INTERPHALANGEAL JOINT STAB     N     3
                      26471    7                      TENODESIS; FOR PROXIMAL INTERPHALANGEAL JOINT STAB     N     3
                      26471    F                      TENODESIS; FOR PROXIMAL INTERPHALANGEAL JOINT STAB     N     3
                      26474    2                      TENODESIS; FOR DISTAL JOINT STABILIZATION              N     3
                      26474    7                      TENODESIS; FOR DISTAL JOINT STABILIZATION              N     3
                      26474    F                      TENODESIS; FOR DISTAL JOINT STABILIZATION              N     3
                      26476    2                      TENDON LENGTHENING, EXTENSOR, SINGLE, EACH             N     3
                      26476    7                      TENDON LENGTHENING, EXTENSOR, SINGLE, EACH             N     3
                      26476    F                      TENDON LENGTHENING, EXTENSOR, SINGLE, EACH             N     3
                      26477    2                      TENDON SHORTENING, EXTENSOR, SINGLE, EACH              N     3
                      26477    7                      TENDON SHORTENING, EXTENSOR, SINGLE, EACH              N     3
                      26477    F                      TENDON SHORTENING, EXTENSOR, SINGLE, EACH              N     3
                      26478    2                      TENDON LENGTHENING,FLEXOR,HAND/FINGER,SINGLE,EACH      N     3
                      26478    7                      TENDON LENGTHENING,FLEXOR,HAND/FINGER,SINGLE,EACH      N     3
                      26478    F                      TENDON LENGTHENING,FLEXOR,HAND/FINGER,SINGLE,EACH      N     3
                      26479    7                      TENDON SHORTENING, FLEXOR, HAND OR FINGER, SINGLE,     N     3
                      26479    F                      TENDON SHORTENING, FLEXOR, HAND OR FINGER, SINGLE,     N     3
                      26480    2                      TENDON TRANSFER OR TRANSPLANT, CARPOMETACARPAL ARE     N     3
                      26480    7                      TENDON TRANSFER OR TRANSPLANT, CARPOMETACARPAL ARE     N     3
                      26480    8                      TENDON TRANSFER OR TRANSPLANT, CARPOMETACARPAL ARE     N     3
                      26480    F                      TENDON TRANSFER OR TRANSPLANT, CARPOMETACARPAL ARE     N     3
                      26483    2                      TENDON TRANSFER OR TRANSPLANT, CARPOMETACARPAL ARE     N     3
                      26483    7                      TENDON TRANSFER OR TRANSPLANT, CARPOMETACARPAL ARE     N     3
                      26483    F                      TENDON TRANSFER OR TRANSPLANT, CARPOMETACARPAL ARE     N     3
                      26485    2                      TENDON TRANSFER OR TRANSPLANT, PALMAR, SINGLE, EA      N     3
                      26485    7                      TENDON TRANSFER OR TRANSPLANT, PALMAR, SINGLE, EA      N     3
                      26485    8                      TENDON TRANSFER OR TRANSPLANT, PALMAR, SINGLE, EA      N     3




Updated: 09/22/2006                                                                                                     Page: 75 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      26485    F                      TENDON TRANSFER OR TRANSPLANT, PALMAR, SINGLE, EA      N     3
                      26489    2                      TENDON TRANSFER OR TRANSPLANT, PALMAR, SINGLE, EA      N     3
                      26489    7                      TENDON TRANSFER OR TRANSPLANT, PALMAR, SINGLE, EA      N     3
                      26489    F                      TENDON TRANSFER OR TRANSPLANT, PALMAR, SINGLE, EA      N     3
                      26490    2                      OPPONENS PLASTY; SUBLIMIS TENDON TRANSFER TYPE         N     3
                      26490    7                      OPPONENS PLASTY; SUBLIMIS TENDON TRANSFER TYPE         N     3
                      26490    F                      OPPONENS PLASTY; SUBLIMIS TENDON TRANSFER TYPE         N     3
                      26492    2                      OPPONENS PLASTY; TENDON TRANSFER WITH GRAFT (INCL      N     3
                      26492    7                      OPPONENS PLASTY; TENDON TRANSFER WITH GRAFT (INCL      N     3
                      26492    8                      OPPONENS PLASTY; TENDON TRANSFER WITH GRAFT (INCL      N     3
                      26492    F                      OPPONENS PLASTY; TENDON TRANSFER WITH GRAFT (INCL      N     3
                      26494    2                      OPPONENS PLASTY; HYPOTHENAR MUSCLE TRANSFER            N     3
                      26494    7                      OPPONENS PLASTY; HYPOTHENAR MUSCLE TRANSFER            N     3
                      26494    F                      OPPONENS PLASTY; HYPOTHENAR MUSCLE TRANSFER            N     3
                      26496    2                      OPPONENS PLASTY; OTHER METHODS                         N     3
                      26496    7                      OPPONENS PLASTY; OTHER METHODS                         N     3
                      26496    8                      OPPONENS PLASTY; OTHER METHODS                         N     3
                      26496    F                      OPPONENS PLASTY; OTHER METHODS                         N     3
                      26497    7                      SUBLIMIS TRANSFER TO CORRECT CLAW FINGER; IV AND V     N     3
                      26497    F                      SUBLIMIS TRANSFER TO CORRECT CLAW FINGER; IV AND V     N     3
                      26498    7                      SUBLIMIS TRANSFER TO CORRECT CLAW FINGER; II, III,     N     3
                      26498    F                      SUBLIMIS TRANSFER TO CORRECT CLAW FINGER; II, III,     N     3
                      26499    7                      CORRECTION CLAW FINGER, OTHER METHODS                  N     3
                      26499    F                      CORRECTION CLAW FINGER, OTHER METHODS                  N     3
                      26500    2                      TENDON PULLEY RECONSTRUCTION; WITH LOCAL TISSUES (     N     3
                      26500    7                      TENDON PULLEY RECONSTRUCTION; WITH LOCAL TISSUES (     N     3
                      26500    F                      TENDON PULLEY RECONSTRUCTION; WITH LOCAL TISSUES (     N     3
                      26502    2                      TENDON PULLEY RECONSTRUCTION; WITH TENDON OR FASCI     N     3
                      26502    7                      TENDON PULLEY RECONSTRUCTION; WITH TENDON OR FASCI     N     3
                      26502    F                      TENDON PULLEY RECONSTRUCTION; WITH TENDON OR FASCI     N     3
                      26504    7                      TENDON PULLEY RECONSTRUCTION                           N     3
                      26504    F                      TENDON PULLEY RECONSTRUCTION                           N     3
                      26508    2                      THENAR MUSCLE RELEASE FOR THUMB CONTRACTURE            N     3
                      26508    7                      THENAR MUSCLE RELEASE FOR THUMB CONTRACTURE            N     3
                      26508    F                      THENAR MUSCLE RELEASE FOR THUMB CONTRACTURE            N     3
                      26510    2                      CROSS INTRINSIC TRANSFER                               N     3
                      26510    7                      CROSS INTRINSIC TRANSFER                               N     3
                      26510    F                      CROSS INTRINSIC TRANSFER                               N     3
                      26516    2                      CAPSULODESIS FOR M-P JOINT STABILIZATION; SINGLE D     N     3
                      26516    7                      CAPSULODESIS FOR M-P JOINT STABILIZATION; SINGLE D     N     3
                      26516    F                      CAPSULODESIS FOR M-P JOINT STABILIZATION; SINGLE D     N     3
                      26517    2                      CAPSULODESIS FOR M-P JOINT STABILIZATION; TWO DIGI     N     3
                      26517    7                      CAPSULODESIS FOR M-P JOINT STABILIZATION; TWO DIGI     N     3
                      26517    F                      CAPSULODESIS FOR M-P JOINT STABILIZATION; TWO DIGI     N     3
                      26518    2                      CAPSULODESIS FOR M-P JOINT STABILIZATION; THREE OR     N     3
                      26518    7                      CAPSULODESIS FOR M-P JOINT STABILIZATION; THREE OR     N     3
                      26518    F                      CAPSULODESIS FOR M-P JOINT STABILIZATION; THREE OR     N     3




Updated: 09/22/2006                                                                                                     Page: 76 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      26520    2                      CAPSULECTOMY FOR CONTRACTURE; METACARPOPHALANGEAL                     N     3
                      26520    7                      CAPSULECTOMY FOR CONTRACTURE; METACARPOPHALANGEAL                     N     3
                      26520    F                      CAPSULECTOMY FOR CONTRACTURE; METACARPOPHALANGEAL                     N     3
                      26525    2                      CAPSULECTOMY FOR CONTRACTURE; INTERPHALANGEAL JOIN                    N     3
                      26525    7                      CAPSULECTOMY FOR CONTRACTURE; INTERPHALANGEAL JOIN                    N     3
                      26525    F                      CAPSULECTOMY FOR CONTRACTURE; INTERPHALANGEAL JOIN                    N     3
                      26530    2                      ARTHROPLASTY, METACARPOPHALANGEAL JOINT; SINGLE, E                    N     3
                      26530    7                      ARTHROPLASTY, METACARPOPHALANGEAL JOINT; SINGLE, E                    N     3
                      26530    8                      ARTHROPLASTY, METACARPOPHALANGEAL JOINT; SINGLE, E                    N     3
                      26530    F                      ARTHROPLASTY, METACARPOPHALANGEAL JOINT; SINGLE, E                    N     3
                      26531    2                      ARTHROPLASTY, METACARPOPHALANGEAL JOINT; WITH PROS                    N     3
                      26531    7                      ARTHROPLASTY, METACARPOPHALANGEAL JOINT; WITH PROS                    N     3
                      26531    F                      ARTHROPLASTY, METACARPOPHALANGEAL JOINT; WITH PROS                    N     3
                      26535    2                      ARTHROPLASTY INTERPHALANGEAL JOINT; SINGLE, EACH                      N     3
                      26535    7                      ARTHROPLASTY INTERPHALANGEAL JOINT; SINGLE, EACH                      N     3
                      26535    F                      ARTHROPLASTY INTERPHALANGEAL JOINT; SINGLE, EACH                      N     3
                      26536    2                      ARTHROPLASTY INTERPHALANGEAL JOINT; WITH PROSTHETI                    N     3
                      26536    7                      ARTHROPLASTY INTERPHALANGEAL JOINT; WITH PROSTHETI                    N     3
                      26536    F                      ARTHROPLASTY INTERPHALANGEAL JOINT; WITH PROSTHETI                    N     3
                      26540    2                      RECONSTRUCTION, COLLATERAL LIGAMENT, METACARPOPHAL                    N     3
                      26540    7                      RECONSTRUCTION, COLLATERAL LIGAMENT, METACARPOPHAL                    N     3
                      26540    8                      RECONSTRUCTION, COLLATERAL LIGAMENT, METACARPOPHAL                    N     3
                      26540    F                      RECONSTRUCTION, COLLATERAL LIGAMENT, METACARPOPHAL                    N     3
                      26541    2                      RECONSTRUCTION, COLLATERAL LIGAMENT, METACARPOPHAL                    N     3
                      26541    7                      RECONSTRUCTION, COLLATERAL LIGAMENT, METACARPOPHAL                    N     3
                      26541    8                      RECONSTRUCTION, COLLATERAL LIGAMENT, METACARPOPHAL                    N     3
                      26541    F                      RECONSTRUCTION, COLLATERAL LIGAMENT, METACARPOPHAL                    N     3
                      26542    7                      PRIMARY REPAIR OF COLLATERAL LIGAMENT, METACARPOPH                    N     3
                      26542    F                      PRIMARY REPAIR OF COLLATERAL LIGAMENT, METACARPOPH                    N     3
                      26545    2                      RECONSTRUCTION, COLLATERAL LIGAMENT, INTERPHALANGE                    N     3
                      26545    7                      RECONSTRUCTION, COLLATERAL LIGAMENT, INTERPHALANGE                    N     3
                      26545    F                      RECONSTRUCTION, COLLATERAL LIGAMENT, INTERPHALANGE                    N     3
                      26546    2                      REPAIR NON-UNIONMETACARPAL OR PHALANX                                 N     3
                      26546    7                      REPAIR NON-UNIION,METACARPAL OR PHALANX,W OR W/O EXTER OR INTER       N     3
                      26546    8                      REPAIR NON-UNION,METACARPAL/PHALANX W OR W/O EXTER/INTERN FIXATIO     N     3
                      26546    F                      REPAIR NON-UNIONMETACARPAL OR PHALANX                                 N     3
                      26548    2                      REPAIR AND RECONSTRUCTION, FINGER, VOLAR PLATE,                       N     3
                      26548    7                      REPAIR AND RECONSTRUCTION, FINGER, VOLAR PLATE,                       N     3
                      26548    F                      REPAIR AND RECONSTRUCTION, FINGER, VOLAR PLATE,                       N     3
                      26550    2                      POLLICIZATION OF A DIGIT                                              N     3
                      26550    7                      POLLICIZATION OF A DIGIT                                              N     3
                      26550    F                      POLLICIZATION OF A DIGIT                                              N     3
                      26551    2                      TOE-TO-HAND TRANSFER W/MICROVASCULAR ANASTOMOSIS; GREAT TOE           N     3
                      26551    7                      TOE-TO-HAND TRANSFER W/MICROVASCULAR ANASTOMOSIS;GREAT TOE WRAP       N     3
                      26551    8                      TOE-TO-HAND TRANSFER W/MICROVASCULAR ANASTOMOSIS;GREAT TOE WRAP       N     3
                      26552    7                      RECONSTRUCTION THUMB WITH TOE                                         N     3
                      26553    2                      TOE-TO-HAND TRANSFER W/MICROVASCULAR ANASTOMOSIS;SINGLE TOE           N     3




Updated: 09/22/2006                                                                                                                    Page: 77 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      26553    7                      TOE-TO-HAND TRANSFER W/MICROVASCULAR ANASTOMOSIS;OTHER THAN GRTOE     N     3
                      26553    8                      TOE-TO-HAND TRANSFER W/MICROVASCULAR ANASTOMOSIS;OTHER THAN GRTOE     N     3
                      26554    2                      TOE-TO-HAND TRANSFER W/MICROVASCULAR ANASTOMOSIS;DOUBLE TOE           N     3
                      26554    7                      TOE-TO-HAND TRANSFER W/MICROVASCULAR ANASTOMOSIS;DOUBLE               N     3
                      26554    8                      TOE-TO-HAND TRANSFER W/MICROVASCULAR ANASTOMOSIS; DOUBLE              N     3
                      26555    2                      POSITIONAL CHANGE OF OTHER FINGER                                     N     3
                      26555    7                      POSITIONAL CHANGE OF OTHER FINGER                                     N     3
                      26555    F                      POSITIONAL CHANGE OF OTHER FINGER                                     N     3
                      26556    2                      FREE TOE JOINT TRANSFER W/MICROVASCULAR ANASTOMOSIS                   N     3
                      26556    7                      FREE TOE JOINT TRANSFER W/MICROVASCULAR ANASTOMOSIS                   N     3
                      26556    8                      FREE TOE JOINT TRANSFER W/MICROVASCULAR ANASTOMOSIS                   N     3
                      26557    7                      TOE TO FINGER TRANSFER; FIRST STAGE                                   N     3
                      26558    7                      TOE TO FINGER TRANSFER; EACH DELAY                                    N     3
                      26559    7                      TOE TO FINGER TRANSFER; SECOND STAGE                                  N     3
                      26560    2                      REPAIR OF SYNDACTYLY (WEB FINGER) EACH WEB SPACE;                     N     3
                      26560    7                      REPAIR OF SYNDACTYLY (WEB FINGER) EACH WEB SPACE;                     N     3
                      26560    F                      REPAIR OF SYNDACTYLY (WEB FINGER) EACH WEB SPACE;                     N     3
                      26561    2                      REPAIR OF SYNDACTYLY (WEB FINGER) EACH WEB SPACE;                     N     3
                      26561    7                      REPAIR OF SYNDACTYLY (WEB FINGER) EACH WEB SPACE;                     N     3
                      26561    8                      REPAIR OF SYNDACTYLY (WEB FINGER) EACH WEB SPACE;                     N     3
                      26561    F                      REPAIR OF SYNDACTYLY (WEB FINGER) EACH WEB SPACE;                     N     3
                      26562    2                      REPAIR OF SYNDACTYLY (WEB FINGER) EACH WEB SPACE;                     N     3
                      26562    7                      REPAIR OF SYNDACTYLY (WEB FINGER) EACH WEB SPACE;                     N     3
                      26562    F                      REPAIR OF SYNDACTYLY (WEB FINGER) EACH WEB SPACE;                     N     3
                      26565    2                      OSTEOTOMY FOR CORRECTION OF DEFORMITY; METACARPAL                     N     3
                      26565    7                      OSTEOTOMY FOR CORRECTION OF DEFORMITY; METACARPAL                     N     3
                      26565    F                      OSTEOTOMY FOR CORRECTION OF DEFORMITY; METACARPAL                     N     3
                      26567    2                      OSTEOTOMY FOR CORRECTION OF DEFORMITY; PHALANX                        N     3
                      26567    7                      OSTEOTOMY FOR CORRECTION OF DEFORMITY; PHALANX                        N     3
                      26567    F                      OSTEOTOMY FOR CORRECTION OF DEFORMITY; PHALANX                        N     3
                      26568    7                      OSTEOPLASTY FOR LENGTHENING OF METACARPAL OR PHALA                    N     3
                      26568    F                      OSTEOPLASTY FOR LENGTHENING OF METACARPAL OR PHALA                    N     3
                      26580    7                      REPAIR CLEFT HAND                                                     N     3
                      26585    7                      REPAIR BIFID DIGIT                                                    N     3
                      26587    2                      RECONSTRUCTION OF SUPERNUMERARY DIGIT, SOFT TISSUE                    N     3
                      26587    7                      RECONSTRUCTION OF SUPERNUMERARY DIGIT, SOFT TISSUE                    N     3
                      26587    F                      RECONSTRUCTION OF SUPERNUMERARY DIGIT, SOFT TISSUE                    N     3
                      26590    2                      REPAIR MACRODACTYLIA                                                  N     3
                      26590    7                      REPAIR MACRODACTYLIA                                                  N     3
                      26590    F                      REPAIR MACRODACTYLIA                                                  N     3
                      26591    2                      REPAIR, INTRINSIC MUSCLES OF HAND (SPECIFY)                           N     3
                      26591    7                      REPAIR, INTRINSIC MUSCLES OF HAND (SPECIFY)                           N     3
                      26591    F                      REPAIR, INTRINSIC MUSCLES OF HAND (SPECIFY)                           N     3
                      26593    2                      RELEASE INTRINSIC MUSCLES OF HAND SPECIFY                             N     3
                      26593    F                      RELEASE INTRINSIC MUSCLES OF HAND SPECIFY                             N     3
                      26596    7                      EXCISION OF CONSTRICTING RING OF FINGER,                              N     3
                      26596    F                      EXCISION OF CONSTRICTING RING OF FINGER,                              N     3




Updated: 09/22/2006                                                                                                                    Page: 78 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      26600    2                      CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITHOUT MAN.EACH     N     3
                      26600    7                      TREATMENT OF CLOSED METACARPAL FRACTURE, SINGLE; W                    N     3
                      26605    2                      TREATMENT OF CLOSED METACARPAL FRACTURE, SINGLE; W                    N     3
                      26605    7                      TREATMENT OF CLOSED METACARPAL FRACTURE, SINGLE; W                    N     3
                      26605    F                      TREATMENT OF CLOSED METACARPAL FRACTURE, SINGLE; W                    N     3
                      26607    2                      TREATMENT OF CLOSED METACARPAL FRACTURE, SINGLE; W                    N     3
                      26607    7                      TRTMT OF CLOSED METACARPIFX SINGLE W/MANIP EACH BN                    N     3
                      26607    F                      TREATMENT OF CLOSED METACARPAL FRACTURE, SINGLE; W                    N     3
                      26608    2                      PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACT                    N     3
                      26608    7                      PERCUTANEOUS SKELETAL FIXATION OF METACAPRAL FRACTURE                 N     3
                      26608    8                      ASSIST.,PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE         N     3
                      26608    F                      PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACT                    N     3
                      26615    2                      OPEN TREATMENT OF CLOSED OR OPEN METACARPAL FRACT.                    N     3
                      26615    7                      OPEN TREATMENT OF CLOSED OR OPEN METACARPAL FRACT.                    N     3
                      26615    F                      OPEN TREATMENT OF CLOSED OR OPEN METACARPAL FRACT.                    N     3
                      26641    2                      TREATMENT OF CARPOMETACARPAL DISLOCATION, THUMB, W                    N     3
                      26641    7                      TREATMENT OF CARPOMETACARPAL DISLOCATION, THUMB, W                    N     3
                      26645    2                      TREATMENT OF CLOSED CARPOMETACARPAL FRACTURE DISLO                    N     3
                      26645    7                      TREATMENT OF CLOSED CARPOMETACARPAL FRACTURE DISLO                    N     3
                      26645    F                      TREATMENT OF CLOSED CARPOMETACARPAL FRACTURE DISLO                    N     3
                      26650    2                      TREATMENT OF CLOSED CARPOMETACARPAL FRACT. DISLOC.                    N     3
                      26650    7                      TREATMENT OF CLOSED CARPOMETACARPAL FRACT. DISLOC.                    N     3
                      26650    F                      TREATMENT OF CLOSED CARPOMETACARPAL FRACT. DISLOC.                    N     3
                      26665    2                      OPEN TREATMENT OF CLOSED OR OPEN CARPOMETACARPAL F                    N     3
                      26665    7                      OPEN TREATMENT OF CLOSED OR OPEN CARPOMETACARPAL F                    N     3
                      26665    8                      OPEN TREATMENT OF CLOSED OR OPEN CARPOMETACARPAL F                    N     3
                      26665    F                      OPEN TREATMENT OF CLOSED OR OPEN CARPOMETACARPAL F                    N     3
                      26670    2                      TREAT. OF CLOSED CARPOMETACARPAL DISLOC OTHER THAN                    N     3
                      26675    2                      TREAT. OF CLOSED CARPOMETACARPAL DISLOC OTHER THAN                    N     3
                      26675    7                      TREAT. OF CLOSED CARPOMETACARPAL DISLOC OTHER THAN                    N     3
                      26675    F                      TREAT. OF CLOSED CARPOMETACARPAL DISLOC OTHER THAN                    N     3
                      26676    2                      TREATMENT OF CLOSED CARPOMETACARPAL DISLOCATION,                      N     3
                      26676    7                      TREATMENT OF CLOSED CARPOMETACARPAL DISLOCATION,                      N     3
                      26676    F                      TREATMENT OF CLOSED CARPOMETACARPAL DISLOCATION,                      N     3
                      26685    2                      OPEN TREAT OF CLSD OR OPEN CARPOMETACARPAL DISLOC                     N     3
                      26685    7                      OPEN TREAT OF CLSD OR OPEN CARPOMETACARPAL DISLOC                     N     3
                      26685    F                      OPEN TREAT OF CLSD OR OPEN CARPOMETACARPAL DISLOC                     N     3
                      26686    2                      OPEN TREAT OF CLSD OR OPEN CARPOMETACARPAL DISLOC                     N     3
                      26686    7                      OPEN TREAT OF CLSD OR OPEN CARPOMETACARPAL DISLOC                     N     3
                      26686    F                      OPEN TREAT OF CLSD OR OPEN CARPOMETACARPAL DISLOC                     N     3
                      26700    2                      TREAT OF CLOSED METACARPOPHALANGEAL DISLOC, SINGLE                    N     3
                      26705    2                      TREAT OF CLOSED METACARPOPHALANGEAL DISLOC, SINGLE                    N     3
                      26705    7                      TREAT OF CLOSED METACARPOPHALANGEAL DISLOC, SINGLE                    N     3
                      26705    F                      TREAT OF CLOSED METACARPOPHALANGEAL DISLOC, SINGLE                    N     3
                      26706    7                      TREATMENT OF CLOSED METACARPOPHALANGEAL DISLOCATIO                    N     3
                      26706    F                      TREATMENT OF CLOSED METACARPOPHALANGEAL DISLOCATIO                    N     3
                      26715    2                      OPEN TREAT OF CLOSED OR OPEN METACARPOPHALANGEAL D                    N     3




Updated: 09/22/2006                                                                                                                    Page: 79 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      26715    7                      OPEN TREAT OF CLOSED OR OPEN METACARPOPHALANGEAL D     N     3
                      26715    F                      OPEN TREAT OF CLOSED OR OPEN METACARPOPHALANGEAL D     N     3
                      26720    2                      TREAT OF CLOSED PHALANGEAL SHAFT FRACTURE, PROXIMA     N     3
                      26725    2                      TREAT OF CLOSED PHALANGEAL SHAFT FRACTURE, PROXIMA     N     3
                      26725    7                      TREAT OF CLOSED PHALANGEAL SHAFT FRACTURE, PROXIMA     N     3
                      26727    2                      TREAT OF UNSTABLE PHALANGEAL SHAFT FRACT, PROX OR      N     3
                      26727    7                      TREAT OF UNSTABLE PHALANGEAL SHAFT FRACT, PROX OR      N     3
                      26727    F                      TREAT OF UNSTABLE PHALANGEAL SHAFT FRACT, PROX OR      N     3
                      26735    2                      OPEN TREAT OF CLOSED OR OPEN PHALANGEAL SHAFT FRAC     N     3
                      26735    7                      OPEN TREAT OF CLOSED OR OPEN PHALANGEAL SHAFT FRAC     N     3
                      26735    F                      OPEN TREAT OF CLOSED OR OPEN PHALANGEAL SHAFT FRAC     N     3
                      26740    2                      TREAT OF CLOSED ARTICULAR FX, INVOLV METACARPOPHAL     N     3
                      26740    7                      TREAT OF CLOSED ARTICULAR FX, INVOLV METACARPOPHAL     N     3
                      26742    2                      TREAT OF CLOSED ARTICULAR FX, INVOLV METACARPOPHAL     N     3
                      26742    7                      TREAT OF CLOSED ARTICULAR FX, INVOLV METACARPOPHAL     N     3
                      26742    F                      TREAT OF CLOSED ARTICULAR FX, INVOLV METACARPOPHAL     N     3
                      26743    2                      TREAT OF CLOSED ARTICULAR FX, INVOLV METACARPOPHAL     N     3
                      26743    7                      TREAT OF CLOSED ARTICULAR FX, INVOLV METACARPOPHAL     N     3
                      26746    2                      OPEN TREAT OF CLOSED OR OPEN ARTICULAR FX, INVOLV      N     3
                      26746    7                      OPEN TREAT OF CLOSED OR OPEN ARTICULAR FX, INVOLV      N     3
                      26746    F                      OPEN TREAT OF CLOSED OR OPEN ARTICULAR FX, INVOLV      N     3
                      26750    2                      TREAT OF CLOSED DISTAL PHALANGEAL FX, FINGER OR TH     N     3
                      26755    2                      TREAT OF CLOSED DISTAL PHALANGEAL FX, FINGER OR TH     N     3
                      26755    7                      TREAT OF CLOSED DISTAL PHALANGEAL FX, FINGER OR TH     N     3
                      26756    2                      TREATMENT OF CLOSED DISTAL PHALANGEAL FRACTURE,        N     3
                      26756    7                      TREATMENT OF CLOSED DISTAL PHALANGEAL FRACTURE,        N     3
                      26756    F                      TREATMENT OF CLOSED DISTAL PHALANGEAL FRACTURE,        N     3
                      26765    2                      OPEN TREATMENT OF CLOSED OR OPEN DISTAL PHALANGEAL     N     3
                      26765    7                      OPEN TREATMENT OF CLOSED OR OPEN DISTAL PHALANGEAL     N     3
                      26765    F                      OPEN TREATMENT OF CLOSED OR OPEN DISTAL PHALANGEAL     N     3
                      26770    2                      TREAT OF CLOSED INTERPHALANGEAL JOINT DISLOC, SING     N     3
                      26775    2                      TREAT OF CLOSED INTERPHALANGEAL JOINT DISLOC, SING     N     3
                      26775    7                      TREAT OF CLOSED INTERPHALANGEAL JOINT DISLOC, SING     N     3
                      26776    2                      RX CLSED PHALANG DISLOC-SINGLE W/MANIP W/ANESTHES      N     3
                      26776    7                      RX CLSD PHALANG DISLOC-SINGLE W/MANIP W/ANESTHESIA     N     3
                      26776    F                      RX CLSED PHALANG DISLOC-SINGLE W/MANIP W/ANESTHES      N     3
                      26785    2                      OPEN TREATMENT OF CLOSED OR OPEN INTERPHALANGEAL J     N     3
                      26785    7                      OPEN TREATMENT OF CLOSED OR OPEN INTERPHALANGEAL J     N     3
                      26785    F                      OPEN TREATMENT OF CLOSED OR OPEN INTERPHALANGEAL J     N     3
                      26803    7                      PERCUTANEOUS SKELETAL FIXATION OF METCARPAL FX EAC     N     3
                      26820    2                      FUSION IN OPPOSITION, THUMB, WITH AUTOGENOUS GRAFT     N     3
                      26820    7                      FUSION IN OPPOSITION, THUMB, WITH AUTOGENOUS GRAFT     N     3
                      26820    F                      FUSION IN OPPOSITION, THUMB, WITH AUTOGENOUS GRAFT     N     3
                      26841    2                      ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH OR     N     3
                      26841    7                      ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH OR     N     3
                      26841    8                      ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH OR     N     3
                      26841    F                      ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH OR     N     3




Updated: 09/22/2006                                                                                                     Page: 80 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      26842    2                      ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, W/ OR W     N     3
                      26842    7                      ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, W/ OR W     N     3
                      26842    8                      ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, W/ OR W     N     3
                      26842    F                      ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, W/ OR W     N     3
                      26843    2                      ARTHRODESIS, CARPOMETACARPAL JOINT, DIGITS, OTHER      N     3
                      26843    7                      ARTHRODESIS, CARPOMETACARPAL JOINT, DIGITS, OTHER      N     3
                      26843    F                      ARTHRODESIS, CARPOMETACARPAL JOINT, DIGITS, OTHER      N     3
                      26844    2                      ARTHRODESIS, CARPOMETACARPAL JOINT, DIGITS, OTHER      N     3
                      26844    7                      ARTHRODESIS, CARPOMETACARPAL JOINT, DIGITS, OTHER      N     3
                      26844    F                      ARTHRODESIS, CARPOMETACARPAL JOINT, DIGITS, OTHER      N     3
                      26850    2                      ARTHRODESIS, METACARPOPHALANGEAL JOINT, WITH OR W/     N     3
                      26850    7                      ARTHRODESIS, METACARPOPHALANGEAL JOINT, WITH OR W/     N     3
                      26850    F                      ARTHRODESIS, METACARPOPHALANGEAL JOINT, WITH OR W/     N     3
                      26852    2                      ARTHRODESIS, METACARPOPHALANGEAL JOINT, WITH OR W/     N     3
                      26852    7                      ARTHRODESIS, METACARPOPHALANGEAL JOINT, WITH OR W/     N     3
                      26852    F                      ARTHRODESIS, METACARPOPHALANGEAL JOINT, WITH OR W/     N     3
                      26860    2                      ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR W/O IN     N     3
                      26860    7                      ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR W/O IN     N     3
                      26860    8                      ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR W/O IN     N     3
                      26860    F                      ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR W/O IN     N     3
                      26861    2                      ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR W/O IN     N     3
                      26861    7                      ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR W/O IN     N     3
                      26861    F                      ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR W/O IN     N     3
                      26862    2                      ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR W/O IN     N     3
                      26862    7                      ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR W/O IN     N     3
                      26862    F                      ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR W/O IN     N     3
                      26863    2                      ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR W/O IN     N     3
                      26863    7                      ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR W/O IN     N     3
                      26863    F                      ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR W/O IN     N     3
                      26910    2                      AMPUTATION, METACARPAL, W/ FINGER OR THUMB (RAY AM     N     3
                      26910    7                      AMPUTATION, METACARPAL, W/ FINGER OR THUMB (RAY AM     N     3
                      26910    F                      AMPUTATION, METACARPAL, W/ FINGER OR THUMB (RAY AM     N     3
                      26951    2                      AMPUTAT, FINGER OR THUMB, PRIM OR SECOND, ANY JT O     N     3
                      26951    7                      AMPUTAT, FINGER OR THUMB, PRIM OR SECOND, ANY JT O     N     3
                      26951    F                      AMPUTAT, FINGER OR THUMB, PRIM OR SECOND, ANY JT O     N     3
                      26952    2                      AMPUTAT, FINGER OR THUMB, PRIM OR SECOND, ANY JT/P     N     3
                      26952    7                      AMPUTAT, FINGER OR THUMB, PRIM OR SECOND, ANY JT/P     N     3
                      26952    F                      AMPUTAT, FINGER OR THUMB, PRIM OR SECOND, ANY JT/P     N     3
                      26989    7                      UNLISTED PROCEDURE, HANDS OR FINGERS                   N     3
                      26990    2                      INCISION AND DRAINAGE; DEEP ABSCESS OR HEMATOMA        N     3
                      26990    7                      INCISION AND DRAINAGE; DEEP ABSCESS OR HEMATOMA.       N     3
                      26990    F                      INCISION AND DRAINAGE; DEEP ABSCESS OR HEMATOMA        N     3
                      26991    2                      INCISION AND DRAINAGE; INFECTED BURSA                  N     3
                      26991    7                      INCISION AND DRAINAGE; INFECTED BURSA                  N     3
                      26991    F                      INCISION AND DRAINAGE; INFECTED BURSA                  N     3
                      26992    2                      INCISION, DEEP, WITH OPENING OF BONE CORTEX FOR OS     N     3
                      26992    7                      INCISION, DEEP, WITH OPENING OF BONE CORTEX FOR OS     N     3




Updated: 09/22/2006                                                                                                     Page: 81 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                          PA IND PAC
                      26995    7                      INCISION, DEEP, W/OPENING OF BONE CORTEX FOR OSTEO               N     3
                      27000    2                      TENOTOMY, ADDUCTOR, SUBCUTANEOUS, CLOSED (SEPARATE               N     3
                      27000    7                      TENOTOMY, ADDUCTOR, SUBCUTANEOUS, CLOSED (SEPARATE               N     3
                      27000    F                      TENOTOMY, ADDUCTOR, SUBCUTANEOUS, CLOSED (SEPARATE               N     3
                      27001    2                      TENOTOMY, ADDUCTOR, SUBCUTRANEOUS, OPEN;UNILATERAL               N     3
                      27001    7                      TENOTOMY, ADDUCTOR, SUBCUTANEOUS, OPEN; UNILATERAL               N     3
                      27001    8                      TENOTOMY,ADDUCTOR,SUBCUTANEOUS,OPEN;UNILATERAL                   N     3
                      27001    F                      TENOTOMY, ADDUCTOR, SUBCUTRANEOUS, OPEN;UNILATERAL               N     3
                      27003    2                      TENOTOMY, ADDUCOR, SUBCT OPEN; W/OBTURATORY                      N     3
                      27003    7                      TENOTOMY, ADDUCTOR, SUBCUTANEOUS, OPEN; W/OBTURATO               N     3
                      27003    8                      TENOTOMY, ADDUCTOR, SUBCUTANEOUS, OPEN; W/OBTURATO               N     3
                      27003    F                      TENOTOMY, ADDUCOR, SUBCT OPEN; W/OBTURATORY                      N     3
                      27005    2                      TENOTOMY, ILIOPSOAS, OPEN (SEPARATE PROCEDURE)                   N     3
                      27005    7                      TENOTOMY, ILIOPSOAS, OPEN (SEPARATE PROCEDURE)                   N     3
                      27005    8                      TENOTOMY, ILIOPSOAS, OPEN (SEPARATE PROCEDURE)                   N     3
                      27006    2                      TENOTOMY, ABDUCTORS, OPEN (SEPARATE PROCEDURE)                   N     3
                      27006    7                      TENOTOMY, ABDUCTORS, OPEN (SEPARATE PROCEDURE)                   N     3
                      27025    2                      OBER-YOUNT FASCIOTOMY, COMBINED W/ SPICA CAST,PINS               N     3
                      27025    7                      OBER-YOUNT FASCIOTOMY, COMBINED W/ SPICA CAST,PINS               N     3
                      27025    8                      OBER-YOUNT FASCIOTOMY, COMBINED W/ SPICA CAST,PINS               N     3
                      27030    2                      ARTHROTOMY, HIP, FOR DRAINAGE;                                   N     3
                      27030    7                      ARTHROTOMY, HIP, FOR DRAINAGE;                                   N     3
                      27030    8                      ARTHROTOMY, HIP, FOR DRAINAGE;                                   N     3
                      27031    7                      ARTHROTOMY, HIP, FOR DRAINAGE; WITH SUCTION IRRIGA               N     3
                      27033    2                      ARTHROTOMY, HIP, FOR EXPLORATION OR REMOVAL OF LOO               N     3
                      27033    7                      ARTHROTOMY, HIP, FOR EXPLORATION OR REMOVAL OF LOO               N     3
                      27033    F                      ARTHROTOMY, HIP, FOR EXPLORATION OR REMOVAL OF LOO               N     3
                      27035    2                      HIP JOINT DENERVATION, INTRA/EXTRAPELVIC INTRA-ART               N     3
                      27035    7                      HIP JOINT DENERVATION, INTRA/EXTRAPELVIC INTRA-ART               N     3
                      27035    F                      HIP JOINT DENERVATION, INTRA/EXTRAPELVIC INTRA-ART               N     3
                      27036    2                      CAPSULECTOMY OR CAPSULOTOMY OF HIP;W OR W/O EXCISION OF BONE     N     3
                      27036    7                      CAPSULECTOMY OR CAPSULOTOME OF HIP W OR W/O EXCISION OF BONE     N     3
                      27036    8                      CAPSULECTOMY OR CAPSULOTOMY OF HIP,W OR W/O EXCISION OF BONE     N     3
                      27040    2                      BIOPSY, SOFT TISSUES; SUPERFICIAL                                N     3
                      27040    F                      BIOPSY, SOFT TISSUES; SUPERFICIAL                                N     3
                      27041    2                      BIOPSY, SOFT TISSUES; DEEP                                       N     3
                      27041    F                      BIOPSY, SOFT TISSUES; DEEP                                       N     3
                      27047    2                      EXCISION, BENIGN TUMOR; SUBCUTANEOUS                             N     3
                      27047    F                      EXCISION, BENIGN TUMOR; SUBCUTANEOUS                             N     3
                      27048    2                      EXCISION, BENIGN TUMOR; DEEP, SUBFASCIAL, INTRAMUS               N     3
                      27048    7                      EXCISION, BENIGN TUMOR; DEEP, SUBFASCIAL, INTRAMUS               N     3
                      27048    F                      EXCISION, BENIGN TUMOR; DEEP, SUBFASCIAL, INTRAMUS               N     3
                      27049    2                      RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM               N     3
                      27049    7                      RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM               N     3
                      27049    F                      RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM               N     3
                      27050    2                      ARTHROTOMY, FOR BIOPSY; SACROILIAC JOINT                         N     3
                      27050    7                      ARTHROTOMY, FOR BIOPSY; SACROILIAC JOINT                         N     3




Updated: 09/22/2006                                                                                                               Page: 82 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      27050    8                      ARTHROTOMY, FOR BIOPSY; SACROILIAC JOINT               N     3
                      27050    F                      ARTHROTOMY, FOR BIOPSY; SACROILIAC JOINT               N     3
                      27052    2                      ARTHROTOMY, FOR BIOPSY; HIP JOINT                      N     3
                      27052    7                      ARTHROTOMY, FOR BIOPSY; HIP JOINT                      N     3
                      27052    8                      ARTHROTOMY, FOR BIOPSY; HIP JOINT                      N     3
                      27052    F                      ARTHROTOMY, FOR BIOPSY; HIP JOINT                      N     3
                      27054    2                      ARTHROTOMY FOR SYNOVECTOMY, HIP JOINT                  N     3
                      27054    7                      ARTHROTOMY FOR SYNOVECTOMY, HIP JOINT                  N     3
                      27054    8                      ARTHROTOMY FOR SYNOVECTOMY, HIP JOINT                  N     3
                      27060    2                      EXCISION; ISCHIAL BURSA                                N     3
                      27060    7                      EXCISION; ISCHIAL BURSA                                N     3
                      27060    F                      EXCISION; ISCHIAL BURSA                                N     3
                      27062    2                      EXCISION; TROCHANTERIC BURSA OR CALCIFICATION          N     3
                      27062    7                      EXCISION; TROCHANGERIC BURSA OR CALCIFICATION          N     3
                      27062    F                      EXCISION; TROCHANTERIC BURSA OR CALCIFICATION          N     3
                      27065    2                      EXCISION OF BONE CYST OR BENIGN TUMOR; SUPERFICIAL     N     3
                      27065    7                      EXCISION OF BONE CYST OR BENIGN TUMOR; SUPERFICIAL     N     3
                      27065    F                      EXCISION OF BONE CYST OR BENIGN TUMOR; SUPERFICIAL     N     3
                      27066    2                      EXCISION OF BONE CYST OR BENIGN TUMOR; DEEP W OR W     N     3
                      27066    7                      EXCISION OF BONE CYST OR BENIGN TUMOR; DEEP W OR W     N     3
                      27066    8                      EXCISION OF BONE CYST OR BENIGN TUMOR; DEEP W OR W     N     3
                      27066    F                      EXCISION OF BONE CYST OR BENIGN TUMOR; DEEP W OR W     N     3
                      27067    2                      EXCISION OF BONE CYST OR BENIGN TUMOR; WITH BONE G     N     3
                      27067    7                      EXCISION OF BONE CYST OR BENIGN TUMOR; WITH BONE G     N     3
                      27067    F                      EXCISION OF BONE CYST OR BENIGN TUMOR; WITH BONE G     N     3
                      27070    2                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3
                      27070    7                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3
                      27071    2                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3
                      27071    7                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3
                      27071    8                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3
                      27075    2                      RADICAL RESECT FOR TUMOR OR INFECT; WING OF ILIUM,     N     3
                      27075    7                      RADICAL RESECT FOR TUMOR OR INFECT; WING OF ILIUM,     N     3
                      27075    8                      RADICAL RESECT FOR TUMOR OR INFECT; WING OF ILIUM,     N     3
                      27076    2                      RADICAL RESECT FOR TUMOR OR INFECT; ILIUM,ACETA,PU     N     3
                      27076    7                      RADICAL RESECT FOR TUMOR OR INFECT; ILIUM,ACETA,PU     N     3
                      27077    2                      RADICAL RESECTION FOR TUMOR OR INFECTION; INNOMINA     N     3
                      27077    7                      RADICAL RESECTION FOR TUMOR OR INFECTION; INNOMINA     N     3
                      27078    2                      RADICAL RESECT FOR TUMOR OR INFECT; ISCHIAL TUBERO     N     3
                      27078    7                      RADICAL RESECT FOR TUMOR OR INFECT; ISCHIAL TUBERO     N     3
                      27079    2                      RADICAL RESEC FOR TUMOR OR INFECT; ISCH. TUBEROSIT     N     3
                      27079    7                      RADICAL RESEC FOR TUMOR OR INFECT; ISCH. TUBEROSIT     N     3
                      27080    2                      COCCYGECTOMY, PRIMARY                                  N     3
                      27080    7                      COCCYGECTOMY, PRIMARY                                  N     3
                      27080    8                      COCCYGECTOMY, PRIMARY                                  N     3
                      27080    F                      COCCYGECTOMY, PRIMARY                                  N     3
                      27086    2                      REMOVAL OF FOREIGN BODY; SUBCUTANEOUS TISSUE           N     3
                      27086    F                      REMOVAL OF FOREIGN BODY; SUBCUTANEOUS TISSUE           N     3




Updated: 09/22/2006                                                                                                     Page: 83 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                              PA IND PAC
                      27087    2                      REMOVAL OF FOREIGN BODY; DEEP                                        N     3
                      27087    7                      REMOVAL OF FOREIGN BODY; DEEP                                        N     3
                      27087    F                      REMOVAL OF FOREIGN BODY; DEEP                                        N     3
                      27088    2                      REMOVAL OF FOREIGN BODY; DEEP, COMPLICATED                           N     3
                      27088    7                      REMOVAL OF FOREIGN BODY; DEEP, COMPLICATED                           N     3
                      27090    2                      REMOVAL OF HIP PROSTHESIS; (SEPARATE PROCEDURE)                      N     3
                      27090    7                      REMOVAL OF HIP PROSTHESIS; (SEPARATE PROCEDURE)                      N     3
                      27090    8                      REMOVAL OF HIP PROSTHESIS; (SEPARATE PROCEDURE)                      N     3
                      27091    2                      REMOVAL OF HIP PROSTHESIS; COMPLICATED, INCLUDING                    N     3
                      27091    7                      REMOVAL OF HIP PROSTHESIS; COMPLICATED, INCLUDING                    N     3
                      27091    8                      REMOVAL OF HIP PROSTHESIS; COMPLICATED, INCLUDING                    N     3
                      27093    2                      INJECTION PROCEDURE FOR HIP ARTHROGRAPHY; WITHOUT                    N     3
                      27095    2                      INJECTION PROCEDURE FOR HIP ARTHROGRAPHY; WITH ANE                   N     3
                      27095    7                      INJECTION PROCD FOR HIP ARTHROGRAPHY W ANESTHESIA                    N     3
                      27096    2                      INJ PROC FOR SACROILIAC JOINT ARTHROGRAPHY &/ ANESTHESIA/STEROID     N     3
                      27097    2                      HAMSTRING RECESSION, PROXIMAL                                        N     3
                      27097    7                      HAMSTRING RECESSION, PROXIMAL                                        N     3
                      27097    8                      HAMSTRING RECESSION, PROXIMAL                                        N     3
                      27097    F                      HAMSTRING RECESSION, PROXIMAL                                        N     3
                      27098    2                      ADDUCTOR TRANSFER TO ISCHIUM                                         N     3
                      27098    7                      ADDUCTOR TRANSFER TO ISCHIUM                                         N     3
                      27098    F                      ADDUCTOR TRANSFER TO ISCHIUM                                         N     3
                      27100    2                      TRANSF EXTERN. OBLIQUE MUSCLE TO GREATER TROCHANTE                   N     3
                      27100    7                      TRANSF EXTERN. OBLIQUE MUSCLE TO GREATER TROCHANTE                   N     3
                      27100    8                      TRANSF EXTERN. OBLIQUE MUSCLE TO GREATER TROCHANTE                   N     3
                      27100    F                      TRANSF EXTERN. OBLIQUE MUSCLE TO GREATER TROCHANTE                   N     3
                      27105    2                      TRANSFER PARASPINAL MUSCLE TO HIP (INCLUDES FASC O                   N     3
                      27105    7                      TRANSFER PARASPINAL MUSCLE TO HIP (INCLUDES FASC O                   N     3
                      27105    8                      TRANSFER PARASPINAL MUSCLE TO HIP (INCLUDES FASC O                   N     3
                      27105    F                      TRANSFER PARASPINAL MUSCLE TO HIP (INCLUDES FASC O                   N     3
                      27110    2                      TRANSFER ILIOPSOAS; TO GREATER TROCHANTER                            N     3
                      27110    7                      TRANSFER ILIOPSOAS; TO GREATER TROCHANTER                            N     3
                      27110    8                      TRANSFER ILIOPSOAS; TO GREATER TROCHANTER                            N     3
                      27110    F                      TRANSFER ILIOPSOAS; TO GREATER TROCHANTER                            N     3
                      27111    2                      TRANSFER ILIOPSOAS; TO FEMORAL NECK                                  N     3
                      27111    7                      TRANSFER ILIOPSOAS; TO FEMORAL NECK                                  N     3
                      27111    8                      TRANSFER ILIOPSOAS; TO FEMORAL NECK                                  N     3
                      27111    F                      TRANSFER ILIOPSOAS; TO FEMORAL NECK                                  N     3
                      27115    2                      MUSCLE RELEASE, COMPLETE (HANGING HIP OPERATION)                     N     3
                      27115    7                      MUSCLE RELEASE, COMPLETE (HANGING HIP OPERATION)                     N     3
                      27115    8                      MUSCLE RELEASE, COMPLETE (HANGING HIP OPERATION)                     N     3
                      27120    2                      ACETABULOPLASTY; (WHITMAN OR COLONNA TYPE PROCEDUR                   N     3
                      27120    7                      ACETABULOPLASTY; (WHITMAN OR COLONNA TYPE PROCEDUR                   N     3
                      27120    8                      ACETABULOPLASTY; (WHITMAN OR COLONNA TYPE PROCEDUR                   N     3
                      27122    2                      ACETABULOPLASTY; RESECTION FEMORAL HEAD (GIRDLESTO                   N     3
                      27122    7                      ACETABULOPLASTY; RESECTION FEMORAL HEAD (GIRDLESTO                   N     3
                      27122    8                      ACETABULOPLASTY; RESECTION FEMORAL HEAD (GIRDLESTO                   N     3




Updated: 09/22/2006                                                                                                                   Page: 84 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      27125    2                      ARTHROPLASTY; PROSTHESIS                               N     3
                      27125    7                      ARTHROPLASTY; PROSTHESIS                               N     3
                      27125    8                      ARTHROPLASTY; PROSTHESIS                               N     3
                      27130    2                      ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROS     N     3
                      27130    7                      ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROS     N     3
                      27130    8                      ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROS     N     3
                      27132    2                      CNVERSN PREV HIP SURG TO TOTAL HIP REPLACEMENT         N     3
                      27132    7                      CONVERSN PREV HIP SURG TO TOTAL HIP REPLACEMENT        N     3
                      27132    8                      CNVERSN PREV HIP SURG TO TOTAL HIP REPLACEMENT         N     3
                      27134    2                      REVISION OF TOTAL HIP ARTROPLAST BTH COMPNTS           N     3
                      27134    7                      REVISION OF TOTAL HIP ARTROPLAST BTH COMPONTS          N     3
                      27134    8                      RVSION TTL HIP ARTHRPLSTY BTH CMPNTS                   N     3
                      27137    2                      REVISION OF TOTAL HIP ARTHROPLASTY                     N     3
                      27137    7                      REVISION OF TOTAL HIP ARTHROPLASTY                     N     3
                      27137    8                      REVISION OF TOTAL HIP ARTHROPLASTY                     N     3
                      27138    2                      REVISION OF TOTAL HIP ARTHROPLASTY                     N     3
                      27138    7                      REVISION OF TOTAL HIP ARTHROPLASTY                     N     3
                      27138    8                      REVISION OF TOTAL HIP ARTHROPLASTY                     N     3
                      27140    2                      OSTEOTOMY AND TRANSFER OF GREATER TROCHANTER (SEPA     N     3
                      27140    7                      OSTEOTOMY AND TRANSFER OF GREATER TROCHANTER (SEPA     N     3
                      27140    8                      OSTEOTOMY AND TRANSFER OF GREATER TROCHANTER (SEPA     N     3
                      27146    2                      OSTEOTOMY, ILIAC OR ACETABULAR OR INNOMINATE BONE;     N     3
                      27146    7                      OSTEOTOMY, ILIAC OR ACETABULAR OR INNOMINATE BONE;     N     3
                      27146    8                      OSTEOTOMY, ILIAC OR ACETABULAR OR INNOMINATE BONE;     N     3
                      27147    2                      OSTEOTOMY, ILIAC OR ACETABULAR OR INNOMINATE BONE;     N     3
                      27147    7                      OSTEOTOMY, ILIAC OR ACETABULAR OR INNOMINATE BONE;     N     3
                      27147    8                      OSTEOTOMY, ILIAC OR ACETABULAR OR INNOMINATE BONE;     N     3
                      27151    2                      OSTEOTOMY, ILIAC OR ACETABULAR OR INNOMINATE BONE;     N     3
                      27151    7                      OSTEOTOMY, ILIAC OR ACETABULAR OR INNOMINATE BONE;     N     3
                      27151    8                      OSTEOTOMY, ILIAC OR ACETABULAR OR INNOMINATE BONE;     N     3
                      27156    2                      OSTEOTOMY, ILIAC OR ACETABULAR OR INNOMINATE BONE;     N     3
                      27156    7                      OSTEOTOMY, ILIAC OR ACETABULAR OR INNOMINATE BONE;     N     3
                      27156    8                      OSTEOTOMY, ILIAC OR ACETABULAR OR INNOMINATE BONE;     N     3
                      27158    2                      OSTEOTOMY, PELVIS, BILATERAL FOR CONGENITAL MALFOR     N     3
                      27158    7                      OSTEOTOMY, PELVIS, BILATERAL FOR CONGENITAL MALFOR     N     3
                      27161    2                      OSTEOTOMY, FEMORAL NECK (SEPARATE PROCEDURE)           N     3
                      27161    7                      OSTEOTOMY, FEMORAL NECK (SEPARATE PROCEDURE)           N     3
                      27161    8                      OSTEOTOMY, FEMORAL NECK (SEPARATE PROCEDURE)           N     3
                      27165    2                      OSTEOTOMY, INTERTROCHANTERIC OR SUBTROCHANTERIC IN     N     3
                      27165    7                      OSTEOTOMY, INTERTROCHANTERIC OR SUBTROCHANTERIC IN     N     3
                      27165    8                      OSTEOTOMY, INTERTROCHANTERIC OR SUBTROCHANTERIC IN     N     3
                      27170    2                      BONE GRAFT FOR NONUNION, FEMORAL HEAD, NECK, INTER     N     3
                      27170    7                      BONE GRAFT FOR NONUNION, FEMORAL HEAD, NECK, INTER     N     3
                      27170    8                      BONE GRAFT FOR NONUNION, FEMORAL HEAD, NECK, INTER     N     3
                      27175    2                      TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; BY TRACTIO     N     3
                      27175    7                      TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; BY TRACTIO     N     3
                      27176    2                      TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; BY SINGLE      N     3




Updated: 09/22/2006                                                                                                     Page: 85 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      27176    7                      TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; BY SINGLE      N     3
                      27176    8                      TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; BY SINGLE      N     3
                      27177    2                      OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; SINGL     N     3
                      27177    7                      OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; SINGL     N     3
                      27177    8                      OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; SINGL     N     3
                      27178    2                      OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; CLOSE     N     3
                      27178    7                      OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; CLOSE     N     3
                      27179    2                      OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; OSTEO     N     3
                      27179    7                      OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; OSTEO     N     3
                      27179    8                      OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; OSTEO     N     3
                      27181    2                      OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; OSTEO     N     3
                      27181    7                      OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; OSTEO     N     3
                      27181    8                      OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; OSTEO     N     3
                      27185    2                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING, G     N     3
                      27185    7                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING, G     N     3
                      27185    8                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING, G     N     3
                      27187    2                      PROPH TRTMT W/WO METHYL METHAC, FEMOR NCK/PROX FEM     N     3
                      27187    7                      PROPH TRTMT W/WO METHYL METHAC/FEMOR NCK/PROX FEM      N     3
                      27187    8                      PROPH TRTMT W/WO METHYL METHAC, FEMOR NCK/PROX FEM     N     3
                      27191    7                      TREATMENT OF CLOSED SACRAL FRACTURE; WITH MANIPULA     N     3
                      27193    2                      CLOSED TREATMENT OF PELVIC RING FRACTURE, DISLOCAT     N     3
                      27193    7                      FRACTURES AND/OR DISLOCATIONS                          N     3
                      27193    F                      CLOSED TREATMENT OF PELVIC RING FRACTURE, DISLOCAT     N     3
                      27194    2                      CLOSED TREATMENT OF PELVIC RING FRACTURE, DISLOCAT     N     3
                      27194    7                      CLOSED TRTMT OF PELVIC RING FX DISLOCATION DIASTAS     N     3
                      27194    F                      CLOSED TREATMENT OF PELVIC RING FRACTURE, DISLOCAT     N     3
                      27200    7                      TREATMENT OF CLOSED COCCYGEAL FRACTURE                 N     3
                      27202    7                      OPEN TREATMENT OF CLOSED OR OPEN COCCYGEAL FRACTUR     N     3
                      27202    F                      OPEN TREATMENT OF CLOSED OR OPEN COCCYGEAL FRACTUR     N     3
                      27211    7                      TREATMENT OF CLOSED ILIAC, PUBIC OR ISCHIAL FRACTU     N     3
                      27215    2                      OPEN TREATMENT OF ILIAC SPINE(S), TUBEROSITY AVULS     N     3
                      27215    7                      OPEN TRTMT OF ILIAC SPINE TUBEROSITY AVULSION OR I     N     3
                      27216    2                      PERCUTANEOUS SKELETAL FIXATION OF POSTERIOR PELVIC     N     3
                      27216    7                      PERCUTANEOUS SKLTL FIXATION OF POSTERIOR PELVIC FX     N     3
                      27217    2                      OPEN TREATMENT OF ANTERIOR RING FRACTURE AND/OR DI     N     3
                      27217    7                      OPEN TRTMT ANTERIOR RING FX AND/OR DISLOCATION         N     3
                      27218    2                      OPEN TREATMENT OF POSTERIOR RING FRACTURE AND/OR D     N     3
                      27218    7                      OPEN TRTNT OF POSTERIOR RING FX AND/OR DISLOCATION     N     3
                      27220    2                      TREATMENT OF CLOSED ACETABULUM (HIP SOCKET) FX(S)      N     3
                      27220    7                      TREATMENT OF CLOSED ACETABULUM (HIP SOCKET) FX(S)      N     3
                      27222    2                      TREATMENT OF CLOSED ACETABULUM (HIP SOCKET) FX(S)      N     3
                      27222    7                      TREATMENT OF CLOSED ACETABULUM (HIP SOCKET) FX(S)      N     3
                      27226    2                      OPEN TREATMENT OF POSTERIOR OR ANTERIOR ACETABULAR     N     3
                      27226    7                      OPEN TRTMT OF POSTERIOR OR ANTERIOR ACETABULAR FX      N     3
                      27227    2                      OPEN TREATMENT OF ACETABULAR FRACTURE(S) INVOLVING     N     3
                      27227    7                      OPEN TRTMT OF ACETABULAR FX INVOLV ANTERIOR 1 COLU     N     3
                      27228    2                      OPEN TREATMENT OF ACETABULAR FRACTURE(S) INVOLVING     N     3




Updated: 09/22/2006                                                                                                     Page: 86 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      27228    7                      OPEN TRTMT OF ACETABULAR FX INVOLV ANTERIOR 2 COLU                    N     3
                      27230    2                      TREATMENT OF CLOSED FEMORAL FRACTURE, PROXIMAL END                    N     3
                      27230    7                      TREATMENT OF CLOSED FEMORAL FRACTURE, PROXIMAL END                    N     3
                      27230    F                      TREATMENT OF CLOSED FEMORAL FRACTURE, PROXIMAL END                    N     3
                      27232    2                      TREATMENT OF CLOSED FEMORAL FRACTURE, PROXIMAL END                    N     3
                      27232    7                      TREATMENT OF CLOSED FEMORAL FRACTURE, PROXIMAL END                    N     3
                      27235    2                      TREAT OF CLOSED OR OPEN FEMORAL FX, PROXIMAL END,                     N     3
                      27235    7                      TREAT OF CLOSED OR OPEN FEMORAL FX, PROXIMAL END,                     N     3
                      27235    8                      TREAT OF CLOSED OR OPEN FEMORAL FX, PROXIMAL END,                     N     3
                      27236    2                      OPEN TREAT OF CLOSED OR OPEN FEMORAL FX, PROXIMAL                     N     3
                      27236    7                      OPEN TREAT OF CLOSED OR OPEN FEMORAL FX, PROXIMAL                     N     3
                      27236    8                      OPEN TREAT OF CLOSED OR OPEN FEMORAL FX, PROXIMAL                     N     3
                      27238    7                      TREAT OF CLOSED INTERTROCHANTERIC OR PERTROCHANTER                    N     3
                      27238    F                      TREAT OF CLOSED INTERTROCHANTERIC OR PERTROCHANTER                    N     3
                      27240    2                      TREAT OF CLOSED INTERTROCHANTERIC OR PERTROCHANTER                    N     3
                      27240    7                      TREAT OF CLOSED INTERTROCHANTERIC OR PERTROCHANTER                    N     3
                      27244    2                      OPEN TREAT OF CLOSED OR OPEN INTERTRO OR PERTROCHANTERIC FEM. FX.     N     3
                      27244    7                      OPEN TREAT OF CLOSED OR OPEN INTERTRO OR PERTROCHA                    N     3
                      27244    8                      OPEN TREAT OF CLOSED OR OPEN INTERTRO OR PERTROCHA                    N     3
                      27245    2                      OPEN TREATMENT OF INTERTROCHANTERIC, PERTROCHANTER                    N     3
                      27245    7                      OPEN TRTMT OF INTEROCHANTERIC PERTOCHAN OR SUBTROC                    N     3
                      27245    8                      OPEN TRTMT OF INTEROCHANTERIC PERTOCHAN OR SUBTROC                    N     3
                      27246    2                      TREATMENT OF CLOSED GREATER TROCHANTERIC FRACTURE,                    N     3
                      27246    7                      TREATMENT OF CLOSED GREATER TROCHANTERIC FRACTURE,                    N     3
                      27246    F                      TREATMENT OF CLOSED GREATER TROCHANTERIC FRACTURE,                    N     3
                      27248    2                      OPEN TREAT OF CLOSED OR OPEN GREATER TROCHANTERIC                     N     3
                      27248    7                      OPEN TREAT OF CLOSED OR OPEN GREATER TROCHANTERIC                     N     3
                      27248    8                      OPEN TREAT OF CLOSED OR OPEN GREATER TROCHANTERIC                     N     3
                      27250    2                      TREATMENT OF CLOSED HIP DISLOCATION, TRAUMATIC; W/                    N     3
                      27250    F                      TREATMENT OF CLOSED HIP DISLOCATION, TRAUMATIC; W/                    N     3
                      27252    2                      TREATMENT OF CLOSED HIP DISLOCATION, TRAUMATIC; RE                    N     3
                      27252    7                      TREATMENT OF CLOSED HIP DISLOCATION, TRAUMATIC; RE                    N     3
                      27252    F                      TREATMENT OF CLOSED HIP DISLOCATION, TRAUMATIC; RE                    N     3
                      27253    2                      OPEN TREAT OF CLOSED OR OPEN HIP DISLOC, TRAUMATIC                    N     3
                      27253    7                      OPEN TREAT OF CLOSED OR OPEN HIP DISLOC, TRAUMATIC                    N     3
                      27253    8                      OPEN TREAT OF CLOSED OR OPEN HIP DISLOC, TRAUMATIC                    N     3
                      27254    2                      OPEN TREAT OF CLOS/OPEN HIP DISLOC, TRAUMATIC, W A                    N     3
                      27254    7                      OPEN TREAT OF CLOS/OPEN HIP DISLOC, TRAUMATIC, W A                    N     3
                      27254    8                      OPEN TREAT OF CLOS/OPEN HIP DISLOC, TRAUMATIC, W A                    N     3
                      27256    2                      TREAT OF CONGENITAL HIP DISLOCATION, BY ABDUCTION,                    N     3
                      27256    7                      TREAT OF CONGENITAL HIP DISLOCATION, BY ABDUCTION,                    N     3
                      27257    2                      TREAT OF CONGENI. HIP DISLOC, BY ABDUCTION, SPLINT                    N     3
                      27257    7                      TREAT OF CONGENI. HIP DISLOC, BY ABDUCTION, SPLINT                    N     3
                      27257    8                      TREAT OF CONGENI. HIP DISLOC, BY ABDUCTION, SPLINT                    N     3
                      27257    F                      TREAT OF CONGENI. HIP DISLOC, BY ABDUCTION, SPLINT                    N     3
                      27258    2                      OPEN TREAT OF CONGENITAL HIP DISLOC; REPLAC OF FEM                    N     3
                      27258    7                      OPEN TREAT OF CONGENITAL HIP DISLOC; REPLAC OF FEM                    N     3




Updated: 09/22/2006                                                                                                                    Page: 87 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      27258    8                      OPEN TREAT OF CONGENITAL HIP DISLOC; REPLAC OF FEM     N     3
                      27259    2                      OPEN TREAT OF CONGENI. HIP DISLOC; REPLAC OF FEMOR     N     3
                      27259    7                      OPEN TREAT OF CONGENI. HIP DISLOC; REPLAC OF FEMOR     N     3
                      27265    2                      TREATMENT OF ATRAUMATIC HIP DISLOCATION (EG, POST-     N     3
                      27265    7                      TREATMENT OF ATRAUMATIC HIP DISLOCATION (EG, POST-     N     3
                      27266    2                      TREATMENT OF ATRAUMATIC HIP DISLOC;REQ GEN ANES        N     3
                      27266    7                      TREATMENT OF ATRAUMATIC HIP DISLOC;REQ GEN ANES        N     3
                      27266    8                      TRTMNT OF ATRAUMATIC HIP DISCLOCATN;REQ GEN ANES       N     3
                      27266    F                      TREATMENT OF ATRAUMATIC HIP DISLOC;REQ GEN ANES        N     3
                      27275    2                      MANIPULATION, HIP JOINT, REQUIRING GENERAL ANESTHE     N     3
                      27275    7                      MANIPULATION, HIP JOINT, REQUIRING GENERAL ANESTHE     N     3
                      27275    F                      MANIPULATION, HIP JOINT, REQUIRING GENERAL ANESTHE     N     3
                      27280    2                      ARTHRODESIS, SACROILIAC JOINT (INCLUDING OBTAINING     N     3
                      27280    7                      ARTHRODESIS, SACROILIAC JOINT (INCLUDING OBTAINING     N     3
                      27280    8                      ARTHRODESIS, SACROILIAC JOINT (INCLUDING OBTAINING     N     3
                      27281    7                      ARTHRODESIS, SACROILIAC JOINT (INCLUDING OBTAINING     N     3
                      27282    7                      ARTHRODESIS, SYMPHYSIS PUBIS (INCLUDING OBTAINING      N     3
                      27284    2                      ARTHRODESIS, HIP JOINT (INCLUDES OBTAINING GRAFT);     N     3
                      27284    7                      ARTHRODESIS, HIP JOINT (INCLUDES OBTAINING GRAFT);     N     3
                      27284    8                      ARTHRODESIS, HIP JOINT (INCLUDES OBTAINING GRAFT);     N     3
                      27286    2                      ARTHRODESIS, HIP JOINT (INCLUDES OBTAINING GRAFT);     N     3
                      27286    7                      ARTHRODESIS, HIP JOINT (INCLUDES OBTAINING GRAFT);     N     3
                      27286    8                      ARTHRODESIS, HIP JOINT (INCLUDES OBTAINING GRAFT);     N     3
                      27290    2                      INTERPELVIABDOMINAL AMPUTATION (HIND QUARTER AMPUT     N     3
                      27290    7                      INTERPELVIABDOMINAL AMPUTATION (HIND QUARTER AMPUT     N     3
                      27290    8                      INTERPELVIABDOMINAL AMPUTATION (HIND QUARTER AMPUT     N     3
                      27295    2                      DISARTICULATION OF HIP                                 N     3
                      27295    7                      DISARTICULATION OF HIP                                 N     3
                      27295    8                      DISARTICULATION OF HIP                                 N     3
                      27299    7                      UNLISTED PROCEDURE, PELVIS OR HIP JOINT                N     3
                      27301    2                      INCIS & DRAINAGE DEEP ABSCESS,INF BURSA/HEMATOMA       N     3
                      27301    7                      INCISION AND DRAINAGE OF DEEP ABSCESS, INFECTED BU     N     3
                      27301    F                      INCIS & DRAINAGE DEEP ABSCESS,INF BURSA/HEMATOMA       N     3
                      27303    2                      INCISION, DEEP, WITH OPENING OF BONE CORTEX FOR OS     N     3
                      27303    7                      INCISION, DEEP, WITH OPENING OF BONE CORTEX FOR OS     N     3
                      27303    8                      INCISION, DEEP, WITH OPENING OF BONE CORTEX FOR OS     N     3
                      27304    7                      INCISION, DEEP, WITH OPENING OF BONE CORTEX FOR OS     N     3
                      27305    2                      FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN                N     3
                      27305    7                      FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN                N     3
                      27305    8                      FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN                N     3
                      27305    F                      FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN                N     3
                      27306    2                      TENOTOMY, SUBCUTANEOUS, CLOSED, ADDUCTOR OR HAMSTR     N     3
                      27306    7                      TENOTOMY, SUBCUTANEOUS, CLOSED, ADDUCTOR OR HAMSTR     N     3
                      27306    F                      TENOTOMY, SUBCUTANEOUS, CLOSED, ADDUCTOR OR HAMSTR     N     3
                      27307    2                      TENOTOMY, SUBCUTANEOUS, CLOSED, ADDUCTOR OR HAMSTR     N     3
                      27307    7                      TENOTOMY, SUBCUTANEOUS, CLOSED, ADDUCTOR OR HAMSTR     N     3
                      27307    F                      TENOTOMY, SUBCUTANEOUS, CLOSED, ADDUCTOR OR HAMSTR     N     3




Updated: 09/22/2006                                                                                                     Page: 88 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      27310    2                      ARTHROTOMY, KNEE, WITH EXPLORATION, DRAINAGE OR RE     N     3
                      27310    7                      ARTHROTOMY, KNEE, WITH EXPLORATION, DRAINAGE OR RE     N     3
                      27310    8                      ARTHROTOMY, KNEE, WITH EXPLORATION, DRAINAGE OR RE     N     3
                      27310    F                      ARTHROTOMY, KNEE, WITH EXPLORATION, DRAINAGE OR RE     N     3
                      27311    7                      ARTHROTOMY, KNEE, WITH EXPLORATION, DRAINAGE OR RE     N     3
                      27315    2                      NEURECTOMY, HAMSTRING MUSCLE                           N     3
                      27315    7                      NEURECTOMY, HAMSTRING MUSCLE                           N     3
                      27315    8                      NEURECTOMY, HAMSTRING MUSCLE                           N     3
                      27315    F                      NEURECTOMY, HAMSTRING MUSCLE                           N     3
                      27320    2                      NEURECTOMY, POPLITEAL (GASTROCNEMIUS)                  N     3
                      27320    7                      NEURECTOMY, POPLITEAL (GASTROCNEMIUS)                  N     3
                      27320    8                      NEURECTOMY, POPLITEAL (GASTROCNEMIUS)                  N     3
                      27320    F                      NEURECTOMY, POPLITEAL (GASTROCNEMIUS)                  N     3
                      27323    2                      BIOPSY, SOFT TISSUES                                   N     3
                      27323    7                      BIOPSY, SOFT TISSUES; SUPERFICIAL                      N     3
                      27323    F                      BIOPSY, SOFT TISSUES                                   N     3
                      27324    2                      BIOPSY, SOFT TISSUES; DEEP                             N     3
                      27324    7                      BIOPSY, SOFT TISSUES; DEEP                             N     3
                      27324    F                      BIOPSY, SOFT TISSUES; DEEP                             N     3
                      27327    2                      EXCISION, BENIGN TUMOR; SUBCUTANEOUS                   N     3
                      27327    7                      EXCISION, BENIGN TUMOR; SUBCUTANEOUS                   N     3
                      27327    F                      EXCISION, BENIGN TUMOR; SUBCUTANEOUS                   N     3
                      27328    2                      EXCISION, BENIGN TUMOR; DEEP, SUBFASCIAL, OR INTRA     N     3
                      27328    7                      EXCISION, BENIGN TUMOR; DEEP, SUBFASCIAL, OR INTRA     N     3
                      27328    8                      EXCISION, BENIGN TUMOR; DEEP, SUBFASCIAL, OR INTRA     N     3
                      27328    F                      EXCISION, BENIGN TUMOR; DEEP, SUBFASCIAL, OR INTRA     N     3
                      27329    2                      RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM     N     3
                      27329    7                      RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM     N     3
                      27329    F                      RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM     N     3
                      27330    2                      ARTHROTOMY, KNEE; FOR SYNOVIAL BIOPSY ONLY             N     3
                      27330    7                      ARTHROTOMY, KNEE; FOR SYNOVIAL BIOPSY ONLY             N     3
                      27330    F                      ARTHROTOMY, KNEE; FOR SYNOVIAL BIOPSY ONLY             N     3
                      27331    2                      ARTHROTOMY, KNEE; W/ JOINT EXPLOR, W OR W/O BIOPSY     N     3
                      27331    7                      ARTHROTOMY KNEE; W/ JOINT EXPLOR, W OR W/O BIOPSY      N     3
                      27331    8                      ARTHROTOMY, KNEE; W/ JOINT EXPLOR, W OR W/O BIOPSY     N     3
                      27331    F                      ARTHROTOMY, KNEE; W/ JOINT EXPLOR, W OR W/O BIOPSY     N     3
                      27332    2                      ARTHROTOMY, KNEE, FOR EXCISION OF SEMILUNAR CARTIL     N     3
                      27332    7                      ARTHROTOMY, KNEE, FOR EXCISION OF SEMILUNAR CARTIL     N     3
                      27332    8                      ARTHROTOMY, KNEE, FOR EXCISION OF SEMILUNAR CARTIL     N     3
                      27332    F                      ARTHROTOMY, KNEE, FOR EXCISION OF SEMILUNAR CARTIL     N     3
                      27333    2                      ARTHROTOMY, KNEE, FOR EXCISION OF SEMILUNAR CARTIL     N     3
                      27333    7                      ARTHROTOMY, KNEE, FOR EXCISION OF SEMILUNAR CARTIL     N     3
                      27333    8                      ARTHROTOMY, KNEE, FOR EXCISION OF SEMILUNAR CARTIL     N     3
                      27333    F                      ARTHROTOMY, KNEE, FOR EXCISION OF SEMILUNAR CARTIL     N     3
                      27334    2                      ARTHROTOMY, KNEE, FOR SYNOVECTOMY; ANTERIOR OR POS     N     3
                      27334    7                      ARTHROTOMY, KNEE, FOR SYNOVECTOMY; ANTERIOR OR POS     N     3
                      27334    8                      ARTHROTOMY, KNEE, FOR SYNOVECTOMY; ANTERIOR OR POS     N     3




Updated: 09/22/2006                                                                                                     Page: 89 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                          PA IND PAC
                      27334    F                      ARTHROTOMY, KNEE, FOR SYNOVECTOMY; ANTERIOR OR POS               N     3
                      27335    2                      ARTHROTOMY, KNEE, FOR SYNOVECTOMY; ANTERIOR AND PO               N     3
                      27335    7                      ARTHROTOMY, KNEE, FOR SYNOVECTOMY; ANTERIOR AND PO               N     3
                      27335    F                      ARTHROTOMY, KNEE, FOR SYNOVECTOMY; ANTERIOR AND PO               N     3
                      27340    2                      EXCISION, PREPATELLAR BURSA                                      N     3
                      27340    7                      EXCISION, PREPATELLAR BURSA                                      N     3
                      27340    F                      EXCISION, PREPATELLAR BURSA                                      N     3
                      27345    2                      EXCISION OF SYNOVIAL CYST OF POPLITEAL SPACE (BAKE               N     3
                      27345    7                      EXCISION OF SYNOVIAL CYST OF POPLITEAL SPACE (BAKE               N     3
                      27345    8                      EXCISION OF SYNOVIAL CYST OF POPLITEAL SPACE (BAKE               N     3
                      27345    F                      EXCISION OF SYNOVIAL CYST OF POPLITEAL SPACE (BAKE               N     3
                      27347    2                      EXCISION OF LESION OF MENISCUS OR CAPSULE CYST GANGLION KNEE     N     3
                      27347    7                      EXCISION OF LESION OF MENISCUS OR CYST GANGLION OF KNEE          N     3
                      27347    8                      EXCISION OF LESION OF MENISCUS OR CYST, GANGLION OF KNEE         N     3
                      27347    F                      EXCISION OF LESION OF MENISCUS OR CAPSULE CYST GANGLION KNEE     N     3
                      27350    2                      PATELLECTOMY OR HEMIPATELLECTOMY                                 N     3
                      27350    7                      PATELLECTOMY OR HEMIPATELLECTOMY                                 N     3
                      27350    8                      PATELLECTOMY OR HEMIPATELLECTOMY                                 N     3
                      27350    F                      PATELLECTOMY OR HEMIPATELLECTOMY                                 N     3
                      27355    2                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR               N     3
                      27355    7                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR               N     3
                      27355    8                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR               N     3
                      27355    F                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR               N     3
                      27356    7                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR               N     3
                      27356    F                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR               N     3
                      27357    2                      EXCIS OR CURETT OF BONE CYST OR BENIGN TUMOR OF FE               N     3
                      27357    7                      EXCIS OR CURETT OF BONE CYST OR BENIGN TUMOR OF FE               N     3
                      27357    8                      EXCIS OR CURETT OF BONE CYST OR BENIGN TUMOR OF FE               N     3
                      27357    F                      EXCIS OR CURETT OF BONE CYST OR BENIGN TUMOR OF FE               N     3
                      27358    7                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR               N     3
                      27358    F                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR               N     3
                      27360    2                      PARTIAL EXCIS (CRATERIZ, SAUCERIZ OR DIAPHYSECTOMY               N     3
                      27360    7                      PARTIAL EXCIS (CRATERIZ, SAUCERIZ OR DIAPHYSECTOMY               N     3
                      27360    8                      PARTIAL EXCIS (CRATERIZ, SAUCERIZ OR DIAPHYSECTOMY               N     3
                      27360    F                      PARTIAL EXCIS (CRATERIZ, SAUCERIZ OR DIAPHYSECTOMY               N     3
                      27361    7                      PART EXCIS (CRATERIZ,SAUCERIZ OR DIAPHYS) OF BONE,               N     3
                      27365    2                      RADICAL RESECTION FOR TUMOR (BONE OR SOFT TISSUE)                N     3
                      27365    7                      RADICAL RESECTION FOR TUMOR (BONE OR SOFT TISSUE)                N     3
                      27370    2                      INJECTION PROCEDURE FOR KNEE ARTHROGRAPHY                        N     3
                      27370    7                      INJECTION PROCEDURE FOR KNEE ARTHROGRAPHY                        N     3
                      27372    2                      REMOVAL FOREIGN BODY, DEEP                                       N     3
                      27372    7                      REMOVAL FOREIGN BODY, DEEP                                       N     3
                      27372    F                      REMOVAL FOREIGN BODY, DEEP                                       N     3
                      27380    2                      SUTURE OF INFRAPATELLAR TENDON; PRIMARY                          N     3
                      27380    7                      SUTURE OF INFRAPATELLAR TENDON; PRIMARY                          N     3
                      27380    8                      SUTURE OF INFRAPATELLAR TENDON; PRIMARY                          N     3
                      27380    F                      SUTURE OF INFRAPATELLAR TENDON; PRIMARY                          N     3




Updated: 09/22/2006                                                                                                               Page: 90 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      27381    2                      SUTURE OF INFRAPATELLAR TENDON; SECONDARY RECONSTR     N     3
                      27381    7                      SUTURE OF INFRAPATELLAR TENDON; SECONDARY RECONSTR     N     3
                      27381    F                      SUTURE OF INFRAPATELLAR TENDON; SECONDARY RECONSTR     N     3
                      27385    2                      SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE;      N     3
                      27385    7                      SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE;      N     3
                      27385    8                      SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE;      N     3
                      27385    F                      SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE;      N     3
                      27386    7                      SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE;      N     3
                      27386    F                      SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE;      N     3
                      27390    2                      TENOTOMY, OPEN, HAMSTRING, KNEE TO HIP; SINGLE         N     3
                      27390    7                      TENOTOMY, OPEN, HAMSTRING, KNEE TO HIP; SINGLE         N     3
                      27390    F                      TENOTOMY, OPEN, HAMSTRING, KNEE TO HIP; SINGLE         N     3
                      27391    2                      TENOTOMY, OPEN, HAMSTRING, KNEE TO HIP; MULTIPLE,      N     3
                      27391    7                      TENOTOMY, OPEN, HAMSTRING, KNEE TO HIP; MULTIPLE,      N     3
                      27391    F                      TENOTOMY, OPEN, HAMSTRING, KNEE TO HIP; MULTIPLE,      N     3
                      27392    2                      TENOTOMY, OPEN, HAMSTRING, KNEE TO HIP; MULTIPLE,      N     3
                      27392    7                      TENOTOMY, OPEN, HAMSTRING, KNEE TO HIP; MULTIPLE,      N     3
                      27392    8                      TENOTOMY, OPEN, HAMSTRING, KNEE TO HIP; MULTIPLE,      N     3
                      27392    F                      TENOTOMY, OPEN, HAMSTRING, KNEE TO HIP; MULTIPLE,      N     3
                      27393    2                      LENGTHENING OF HAMSTRING TENDON; SINGLE                N     3
                      27393    7                      LENGTHENING OF HAMSTRING TENDON; SINGLE                N     3
                      27393    8                      LENGTHENING OF HAMSTRING TENDON; SINGLE                N     3
                      27393    F                      LENGTHENING OF HAMSTRING TENDON; SINGLE                N     3
                      27394    2                      LENGTHENING OF HAMSTRING TENDON; MULTIPLE, ONE LEG     N     3
                      27394    7                      LENGTHENING OF HAMSTRING TENDON; MULTIPLE, ONE LEG     N     3
                      27394    8                      LENGTHENING OF HAMSTRING TENDON; MULTIPLE, ONE LEG     N     3
                      27394    F                      LENGTHENING OF HAMSTRING TENDON; MULTIPLE, ONE LEG     N     3
                      27395    2                      LENGTHENING OF HAMSTRING TENDON; MULTIPLE, BILATER     N     3
                      27395    7                      LENGTHENING OF HAMSTRING TENDON; MULTIPLE, BILATER     N     3
                      27395    8                      LENGTHENING OF HAMSTRING TENDON; MULTIPLE, BILATER     N     3
                      27395    F                      LENGTHENING OF HAMSTRING TENDON; MULTIPLE, BILATER     N     3
                      27396    2                      TRANSPLANT, HAMSTRING TENDON TO PATELLA; SINGLE        N     3
                      27396    7                      TRANSPLANT, HAMSTRING TENDON TO PATELLA; SINGLE        N     3
                      27396    8                      TRANSPLANT, HAMSTRING TENDON TO PATELLA; SINGLE        N     3
                      27396    F                      TRANSPLANT, HAMSTRING TENDON TO PATELLA; SINGLE        N     3
                      27397    7                      TRANSPLANT, HAMSTRING TENDON TO PATELLA; MULTIPLE      N     3
                      27397    F                      TRANSPLANT, HAMSTRING TENDON TO PATELLA; MULTIPLE      N     3
                      27400    2                      TENDON OR MUSCLE TRANSFER, HAMSTRINGS TO FEMUR (EG     N     3
                      27400    7                      TENDON OR MUSCLE TRANSFER, HAMSTRINGS TO FEMUR (EG     N     3
                      27400    8                      TENDON OR MUSCLE TRANSFER, HAMSTRINGS TO FEMUR (EG     N     3
                      27400    F                      TENDON OR MUSCLE TRANSFER, HAMSTRINGS TO FEMUR (EG     N     3
                      27403    2                      ARTHROTOMY W OPEN MEISCUSREPR                          N     3
                      27403    7                      ARTHROTOMY W OPEN MEISCUSREPR                          N     3
                      27403    8                      ARTHROTOMY W OPEN MEISCUSREPR                          N     3
                      27403    F                      ARTHROTOMY W OPEN MEISCUSREPR                          N     3
                      27405    2                      SUTURE, PRIM, TORN, RUPT OR SEVERED LIGAMENT, W OR     N     3
                      27405    7                      SUTURE, PRIM, TORN, RUPT OR SEVERED LIGAMENT, W OR     N     3




Updated: 09/22/2006                                                                                                     Page: 91 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      27405    8                      SUTURE, PRIM, TORN, RUPT OR SEVERED LIGAMENT, W OR     N     3
                      27405    F                      SUTURE, PRIM, TORN, RUPT OR SEVERED LIGAMENT, W OR     N     3
                      27407    2                      SUTURE, PRIM, TORN, RUPT OR SEVERED LIGAMENT, W OR     N     3
                      27407    7                      SUTURE, PRIM, TORN, RUPT OR SEVERED LIGAMENT, W OR     N     3
                      27407    8                      SUTURE, PRIM, TORN, RUPT OR SEVERED LIGAMENT, W OR     N     3
                      27407    F                      SUTURE, PRIM, TORN, RUPT OR SEVERED LIGAMENT, W OR     N     3
                      27409    2                      SUTUR, PRIM, TORN, RUPT OR SEVERED LIG, W OR W/O M     N     3
                      27409    7                      SUTUR, PRIM, TORN, RUPT OR SEVERED LIG, W OR W/O M     N     3
                      27409    8                      SUTUR, PRIM, TORN, RUPT OR SEVERED LIG, W OR W/O M     N     3
                      27409    F                      SUTUR, PRIM, TORN, RUPT OR SEVERED LIG, W OR W/O M     N     3
                      27412    2                      AUTOLOGOUS CHONDROCYTE                                 Y     3
                      27412    7                      AUTOLOGOUS CHONDROCYTE                                 Y     3
                      27415    2                      OSTEOCHONDRAL ALLOGRAFT, KNEE OPEN                     Y     3
                      27415    7                      OSTEOCHONDRAL ALLOGRAFT, KNEE OPEN                     Y     3
                      27418    2                      ANTERIOR TIBIAL TUBERCLE PLASTY FOR CHONDROMALACIA     N     3
                      27418    7                      ANTERIOR TIBIAL TUBERCLE PLASTY FOR CHONDROMALACIA     N     3
                      27418    8                      ANTERIOR TIBIAL TUBERCLE PLASTY FOR CHONDROMALACIA     N     3
                      27418    F                      ANTERIOR TIBIAL TUBERCLE PLASTY FOR CHONDROMALACIA     N     3
                      27420    2                      RECONSTRUCTION FOR RECURRENT DISLOCATING PATELLA;      N     3
                      27420    7                      RECONSTRUCTION FOR RECURRENT DISLOCATING PATELLA;      N     3
                      27420    8                      RECONSTRUCTION FOR RECURRENT DISLOCATING PATELLA;      N     3
                      27420    F                      RECONSTRUCTION FOR RECURRENT DISLOCATING PATELLA;      N     3
                      27422    2                      RECONST FOR RECUR DISLOC PATELLA; W/EXTENSOR REALI     N     3
                      27422    7                      RECONST FOR RECUR DISLOC PATELLA; W/EXTENSOR REALI     N     3
                      27422    8                      RECONST FOR RECUR DISLOC PATELLA; W/EXTENSOR REALI     N     3
                      27422    F                      RECONST FOR RECUR DISLOC PATELLA; W/EXTENSOR REALI     N     3
                      27424    2                      [21~NSTRUCTION FOR RECURRENT DISLOCATING PATELLA;      N     3
                      27424    7                      RECONSTRUCTION FOR RECURRENT DISLOCATING PATELLA;      N     3
                      27424    8                      RECONSTRUCTION FOR RECURRENT DISLOCATING PATELLA;      N     3
                      27424    F                      [21~NSTRUCTION FOR RECURRENT DISLOCATING PATELLA;      N     3
                      27425    2                      LATERAL RETINACULAR RELEASE (ANY METHOD)               N     3
                      27425    7                      LATERAL RETINACULAR RELEASE (ANY METHOD)               N     3
                      27425    F                      LATERAL RETINACULAR RELEASE (ANY METHOD)               N     3
                      27427    2                      LIGAMENTOUS RECONSTRUCTION (AUGMENTATION) KNEE EXT     N     3
                      27427    7                      LIGAMENTOUS RECONSTRUCTION (AUGMENTATION) KNEE EXT     N     3
                      27427    8                      LIGAMENTOUS RECONSTRUCTION (AUGMENTATION) KNEE EXT     N     3
                      27427    F                      LIGAMENTOUS RECONSTRUCTION (AUGMENTATION) KNEE EXT     N     3
                      27428    2                      RECONSTRUC (AUGMENT) KNEE INTRA ARTIC (OPEN)           N     3
                      27428    7                      RECONSRUC (AUGMENT) KNEE INTRA ARTIC (OPEN)            N     3
                      27428    8                      RECONSTRUCTION (AUG) KNEE INTRA-ARTICULAR OPEN         N     3
                      27428    F                      RECONSTRUC (AUGMENT) KNEE INTRA ARTIC (OPEN)           N     3
                      27429    2                      LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE        N     3
                      27429    7                      LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE        N     3
                      27429    8                      LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE        N     3
                      27429    F                      LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE        N     3
                      27430    2                      QUADRICEPS PLASTY (BENNETT OR THOMPSON TYPE)           N     3
                      27430    7                      QUADRICEPS PLASTY (BENNETT OR THOMPSON TYPE)           N     3




Updated: 09/22/2006                                                                                                     Page: 92 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      27430    8                      QUADRICEPS PLASTY (BENNETT OR THOMPSON TYPE)           N     3
                      27430    F                      QUADRICEPS PLASTY (BENNETT OR THOMPSON TYPE)           N     3
                      27435    2                      CAPSULOTOMY, KNEE, POSTERIOR CAPSULAR RELEASE          N     3
                      27435    7                      CAPSULOTOMY, KNEE, POSTERIOR CAPSULAR RELEASE          N     3
                      27435    8                      CAPSULOTOMY, KNEE, POSTERIOR CAPSULAR RELEASE          N     3
                      27435    F                      CAPSULOTOMY, KNEE, POSTERIOR CAPSULAR RELEASE          N     3
                      27437    7                      ARTHROPLASTY, PATELLA; WITHOUT PROSTHESIS              N     3
                      27437    F                      ARTHROPLASTY, PATELLA; WITHOUT PROSTHESIS              N     3
                      27438    7                      ARTHROPLASTY, PATELLA, WITH PROSTHESIS                 N     3
                      27438    F                      ARTHROPLASTY, PATELLA, WITH PROSTHESIS                 N     3
                      27440    2                      ARTHROPLASTY, KNEE, TIBIAL PLATEAU;                    N     3
                      27440    7                      ARTHROPLASTY, KNEE, TIBIAL PLATEAU;                    N     3
                      27440    8                      ARTHROPLASTY, KNEE, TIBIAL PLATEAU;                    N     3
                      27441    7                      ARTHROPLASTY, KNEE, TIBIAL PLATEAU; WITH DEBRIDEME     N     3
                      27441    F                      ARTHROPLASTY, KNEE, TIBIAL PLATEAU; WITH DEBRIDEME     N     3
                      27442    2                      ARTHROPLASTY, KNEE, FEMORAL CONDYLES OR TIBIAL PLA     N     3
                      27442    7                      ARTHROPLASTY, KNEE, FEMORAL CONDYLES OR TIBIAL PLA     N     3
                      27442    8                      ARTHROPLASTY, KNEE, FEMORAL CONDYLES OR TIBIAL PLA     N     3
                      27442    F                      ARTHROPLASTY, KNEE, FEMORAL CONDYLES OR TIBIAL PLA     N     3
                      27443    2                      ARTHROPLASTY, KNEE, FEMORAL CONDYLES OR TIBIAL PLA     N     3
                      27443    7                      ARTHROPLASTY, KNEE, FEMORAL CONDYLES OR TIBIAL PLA     N     3
                      27443    8                      ARTHROPLASTY, KNEE, FEMORAL CONDYLES OR TIBIAL PLA     N     3
                      27443    F                      ARTHROPLASTY, KNEE, FEMORAL CONDYLES OR TIBIAL PLA     N     3
                      27444    7                      ARTHROPLASTY, KNEE, TOTAL; FASCIAL                     N     3
                      27445    2                      ARTHROPLASTY, KNEE, TOTAL; PROSTHETIC (EG, WALLDIU     N     3
                      27445    7                      ARTHROPLASTY, KNEE, TOTAL; PROSTHETIC (EG, WALLDIU     N     3
                      27445    8                      ARTHROPLASTY, KNEE, TOTAL; PROSTHETIC (EG, WALLDIU     N     3
                      27446    2                      ARTHROPLASTY, KNEE, TOTAL, CONDYLE AND PLATEAU ("T     N     3
                      27446    7                      ARTHROPLASTY, KNEE, TOTAL, CONDYLE AND PLATEAU ("T     N     3
                      27446    8                      ARTHROPLASTY, KNEE, TOTAL, CONDYLE AND PLATEAU ("T     N     3
                      27447    2                      ARTHROPLASTY, KNEE, TOTAL, CONDYLE AND PLATEAU ("T     N     3
                      27447    7                      ARTHROPLASTY, KNEE, TOTAL, CONDYLE AND PLATEAU ("T     N     3
                      27447    8                      ARTHROPLASTY, KNEE, TOTAL, CONDYLE AND PLATEAU ("T     N     3
                      27448    2                      OSTEOTOMY, FEMUR, SHAFT OR SUPRACONDYLAR, WITHOUT      N     3
                      27448    7                      OSTEOTOMY, FEMUR, SHAFT OR SUPRACONDYLAR, WITHOUT      N     3
                      27448    8                      OSTEOTOMY, FEMUR, SHAFT OR SUPRACONDYLAR, WITHOUT      N     3
                      27449    7                      OSTEOTOMY, FEMUR, SHAFT OR SUPRACONDYLAR, WITHOUT      N     3
                      27450    2                      OSTEOTOMY, FEMUR, SHAFT OR SUPRACONDYLAR, WITH FIX     N     3
                      27450    7                      OSTEOTOMY, FEMUR, SHAFT OR SUPRACONDYLAR, WITH FIX     N     3
                      27450    8                      OSTEOTOMY, FEMUR, SHAFT OR SUPRACONDYLAR, WITH FIX     N     3
                      27452    7                      OSTEOTOMY, FEMUR, SHAFT OR SUPRACONDYLAR, WITH FIX     N     3
                      27454    2                      OSTEOTOMY, MULTIPLE, FEMORAL SHAFT, WITH REALIGNME     N     3
                      27454    7                      OSTEOTOMY, MULTIPLE, FEMORAL SHAFT, WITH REALIGNME     N     3
                      27454    8                      OSTEOTOMY, MULTIPLE, FEMORAL SHAFT, WITH REALIGNME     N     3
                      27455    2                      OSTEO,PROX TIB,INCL FIBUL EXCIS/OSTEO(INCL COR. GE     N     3
                      27455    7                      OSTEO,PROX TIB,INCL FIBUL EXCIS/OSTEO(INCL COR. GE     N     3
                      27455    8                      OSTEO,PROX TIB,INCL FIBUL EXCIS/OSTEO(INCL COR. GE     N     3




Updated: 09/22/2006                                                                                                     Page: 93 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      27457    2                      OSTEO,PROX TIB,INCL FIBUL EXCIS/OSTEO(INCL COR. GE     N     3
                      27457    7                      OSTEO,PROX TIB,INCL FIBUL EXCIS/OSTEO(INCL COR. GE     N     3
                      27457    8                      OSTEO,PROX TIB,INCL FIBUL EXCIS/OSTEO(INCL COR. GE     N     3
                      27460    2                      OSTEO,PROX TIB,INCL FIBUL EXCIS/OSTEO(INCL COR. GE     N     3
                      27460    7                      OSTEO,PROX TIB,INCL FIBUL EXCIS/OSTEO(INCL COR. GE     N     3
                      27460    8                      OSTEO,PROX TIB,INCL FIBUL EXCIS/OSTEO(INCL COR. GE     N     3
                      27462    7                      OSTEO,PROX TIB,INCL FIBUL EXCIS/OSTEO(INCL COR. GE     N     3
                      27465    2                      OSTEOPLASTY, FEMUR; SHORTENING                         N     3
                      27465    7                      OSTEOPLASTY, FEMUR; SHORTENING                         N     3
                      27465    8                      OSTEOPLASTY, FEMUR; SHORTENING                         N     3
                      27466    2                      OSTEOPLASTY, FEMUR; LENGTHENING                        N     3
                      27466    7                      OSTEOPLASTY, FEMUR; LENGTHENING                        N     3
                      27468    7                      OSTEOPLASTY, FEMUR; COMBINED, LENGTHENING/SHORTENI     N     3
                      27470    2                      REPAIR, NONUNION OR MALUNION, FEMUR, DISTAL TO HEA     N     3
                      27470    7                      REPAIR, NONUNION OR MALUNION, FEMUR, DISTAL TO HEA     N     3
                      27470    8                      REPAIR, NONUNION OR MALUNION, FEMUR, DISTAL TO HEA     N     3
                      27472    2                      REPAIR,NONUNION/MALUNION,FEMUR, DISTAL TO HD & NEC     N     3
                      27472    7                      REPAIR,NONUNION/MALUNION,FEMUR, DISTAL TO HD & NEC     N     3
                      27472    8                      REPAIR,NONUNION/MALUNION,FEMUR, DISTAL TO HD & NEC     N     3
                      27475    2                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; D     N     3
                      27475    7                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; D     N     3
                      27475    8                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; D     N     3
                      27477    2                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; T     N     3
                      27477    7                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; T     N     3
                      27477    8                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; T     N     3
                      27479    2                      EPIPHY ARREST BY EPIPHYSIODESIS OR STAPLING; COMBI     N     3
                      27479    7                      EPIPHY ARREST BY EPIPHYSIODESIS OR STAPLING; COMBI     N     3
                      27479    8                      EPIPHY ARREST BY EPIPHYSIODESIS OR STAPLING; COMBI     N     3
                      27485    2                      ARREST, HEMIEPIPHYSEAL, DISTAL FEMUR OR PROXIMAL L     N     3
                      27485    7                      ARREST, HEMIEPIPHYSEAL, DISTAL FEMUR OR PROXIMAL L     N     3
                      27485    8                      ARREST, HEMIEPIPHYSEAL, DISTAL FEMUR OR PROXIMAL L     N     3
                      27486    2                      REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHO     N     3
                      27486    7                      REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHO     N     3
                      27486    8                      REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHO     N     3
                      27487    2                      SECONDARY RECONSTRUCTION FOR REVISION OF TOTAL KNE     N     3
                      27487    7                      SECONDARY RECONSTRUCTION FOR REVISION OF TOTAL KNE     N     3
                      27487    8                      SECONDARY RECONSTRUCTION FOR REVISION OF TOTAL KNE     N     3
                      27488    2                      REMOVAL OF KNEE PROSTHESIS, INCLUDING "TOTAL KNEE"     N     3
                      27488    7                      REMOVAL OF KNEE PROSTHESIS, INCLUDING "TOTAL KNEE"     N     3
                      27488    8                      REMOVAL OF KNEE PROSTHESIS, INCLUDING "TOTAL KNEE"     N     3
                      27495    2                      PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING      N     3
                      27495    7                      PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING      N     3
                      27495    8                      PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING      N     3
                      27496    2                      DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, ONE C     N     3
                      27496    7                      DECOMPRESSION FASCIOTOMY THIGH AND/OR KNEE 1 COMPT     N     3
                      27496    F                      DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, ONE C     N     3
                      27497    2                      DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, ONE C     N     3




Updated: 09/22/2006                                                                                                     Page: 94 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      27497    7                      DECOMP FASCIOTOMY THIGH/KNEE 1COMPT W/DEBRIDEMENT      N     3
                      27497    F                      DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, ONE C     N     3
                      27498    2                      DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, MULTI     N     3
                      27498    7                      DECOMPRESSION FASCITOMY THIGH/KNEE MULTIPLE COMPAR     N     3
                      27498    F                      DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, MULTI     N     3
                      27499    2                      DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, MULTI     N     3
                      27499    7                      DECOMP FASCIOTOMY THIGH/KNEE MULTIP COMPT W/DEBRID     N     3
                      27499    F                      DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, MULTI     N     3
                      27500    2                      TREATMENT OF CLOSED FEMORAL SHAFT FX (INCLUD SUPRA     N     3
                      27500    7                      TREATMENT OF CLOSED FEMORAL SHAFT FX (INCLUD SUPRA     N     3
                      27500    F                      TREATMENT OF CLOSED FEMORAL SHAFT FX (INCLUD SUPRA     N     3
                      27501    2                      CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR     N     3
                      27501    7                      CLOSED TRTMT SUPARCNDLR/TRANSCNDYLR FEML W/O MANIL     N     3
                      27501    F                      CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR     N     3
                      27502    2                      TREATMENT OF CLOSED FEMORAL SHAFT FX (INCLUD SUPRA     N     3
                      27502    7                      TREATMENT OF CLOSED FEMORAL SHAFT FX (INCLUD SUPRA     N     3
                      27502    F                      TREATMENT OF CLOSED FEMORAL SHAFT FX (INCLUD SUPRA     N     3
                      27503    2                      CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR     N     3
                      27503    7                      CLOSED TRTMT SUPARCNDLR/TRANSCNDYLR FEML W/MANIPLT     N     3
                      27503    F                      CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR     N     3
                      27506    2                      OPEN TREAT OF CLOSED OR OPEN FEMORAL SHAFT FX(INCL     N     3
                      27506    7                      OPEN TREAT OF CLOSED OR OPEN FEMORAL SHAFT FX(INCL     N     3
                      27506    8                      OPEN TREAT OF CLOSED OR OPEN FEMORAL SHAFT FX(INCL     N     3
                      27507    2                      OPEN TREATMENT OF FEMORAL SHAFT FRACTURE WITH PLAT     N     3
                      27507    7                      OPEN TRTMT OF FEMORL SHAFT FX WITH PLATE/SCREWS        N     3
                      27507    8                      OPEN TRTMT OF FEMORL SHAFT FX WITH PLATE/SCREWS        N     3
                      27508    2                      TREAT OF CLOSED FEMORAL FX, DISTAL END, MEDIAL OR      N     3
                      27508    7                      TREAT OF CLOSED FEMORAL FX, DISTAL END, MEDIAL OR      N     3
                      27508    F                      TREAT OF CLOSED FEMORAL FX, DISTAL END, MEDIAL OR      N     3
                      27509    2                      PERCUTANEOUS SKELETAL FIXATION OF SUPRACONDYLAR OR     N     3
                      27509    7                      PERCUTANEOUS SKLTL FIXATION SUPRACONDLR OR TRANSCD     N     3
                      27509    F                      PERCUTANEOUS SKELETAL FIXATION OF SUPRACONDYLAR OR     N     3
                      27510    2                      TREAT OF CLOSED FEMORAL FX, DISTAL END, MEDIAL OR      N     3
                      27510    7                      TREAT OF CLOSED FEMORAL FX, DISTAL END, MEDIAL OR      N     3
                      27510    F                      TREAT OF CLOSED FEMORAL FX, DISTAL END, MEDIAL OR      N     3
                      27511    2                      OPEN TREATMENT OF FEMORAL SUPRACONDYLAR OR TRANSCO     N     3
                      27511    7                      OPEN TRTMT OF FEMORAL SUPRACONDYLR OR TRANSSCNDR       N     3
                      27513    2                      OPEN TREATMENT OF FEMORAL SUPRACONDYLAR OR TRANSCO     N     3
                      27513    7                      OPEN TRTMT OF FEMORAL SUPRACONDYLR OR TRANSSCNDR       N     3
                      27513    8                      OPEN TRTMT OF FEMORAL SUPRACONDYLR OR TRANSSCNDR       N     3
                      27514    2                      OPEN TRT OF CLSD/OPEN FEMORAL FX,DIST END,MEDIAL O     N     3
                      27514    7                      OPEN TRT OF CLSD/OPEN FEMORAL FX,DIST END,MEDIAL O     N     3
                      27514    8                      OPEN TRT OF CLSD/OPEN FEMORAL FX,DIST END,MEDIAL O     N     3
                      27516    F                      TREAT OF CLOSED DISTAL FEMORAL EPIPHYSEAL SEPARATI     N     3
                      27517    2                      TREATMENT OF CLOSED DISTAL FEMORAL EPIPHYSEAL SEPA     N     3
                      27517    7                      TREATMENT OF CLOSED DISTAL FEMORAL EPIPHYSEAL SEPA     N     3
                      27517    F                      TREATMENT OF CLOSED DISTAL FEMORAL EPIPHYSEAL SEPA     N     3




Updated: 09/22/2006                                                                                                     Page: 95 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      27519    2                      OPEN TREAT OF CLSD OR OPEN DISTAL FEMORAL EPIPHYSE     N     3
                      27519    7                      OPEN TREAT OF CLSD OR OPEN DISTAL FEMORAL EPIPHYSE     N     3
                      27519    8                      OPEN TREAT OF CLSD OR OPEN DISTAL FEMORAL EPIPHYSE     N     3
                      27520    2                      TREATMENT OF CLOSED PATELLAR FRACTURE, WITHOUT MAN     N     3
                      27520    7                      TREATMENT OF CLOSED PATELLAR FRACTURE, WITHOUT MAN     N     3
                      27520    F                      TREATMENT OF CLOSED PATELLAR FRACTURE, WITHOUT MAN     N     3
                      27524    2                      OPEN TREATMENT OF CLOSED OR OPEN PATELLAR FRACTURE     N     3
                      27524    7                      OPEN TREATMENT OF CLOSED OR OPEN PATELLAR FRACTURE     N     3
                      27524    8                      OPEN TREATMENT OF CLOSED OR OPEN PATELLAR FRACTURE     N     3
                      27530    2                      TREATMENT OF CLOSED TIBIAL FRACTURE, PROXIMAL (PLA     N     3
                      27530    7                      TREATMENT OF CLOSED TIBIAL FRACTURE, PROXIMAL (PLA     N     3
                      27530    F                      TREATMENT OF CLOSED TIBIAL FRACTURE, PROXIMAL (PLA     N     3
                      27532    2                      TREATMENT OF CLOSED TIBIAL FRACTURE, PROXIMAL (PLA     N     3
                      27532    7                      TREATMENT OF CLOSED TIBIAL FRACTURE, PROXIMAL (PLA     N     3
                      27532    F                      TREATMENT OF CLOSED TIBIAL FRACTURE, PROXIMAL (PLA     N     3
                      27535    2                      OPEN TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATE     N     3
                      27535    7                      OPEN TRTMT OF TIBIAL FX PROXIMAL PALTEAU               N     3
                      27536    2                      OPEN TREAT OF CLOSD OR OPEN TIBIAL FX, PROXIMAL (P     N     3
                      27536    7                      OPEN TREAT OF CLOSD OR OPEN TIBIAL FX, PROXIMAL (P     N     3
                      27536    8                      OPEN TREAT OF CLOSD OR OPEN TIBIAL FX, PROXIMAL (P     N     3
                      27538    2                      TREATMENT OF CLOSED INTERCONDYLAR SPINE(S) FRACTUR     N     3
                      27538    7                      TREATMENT OF CLOSED INTERCONDYLAR SPINE(S) FRACTUR     N     3
                      27538    F                      TREATMENT OF CLOSED INTERCONDYLAR SPINE(S) FRACTUR     N     3
                      27540    2                      OPEN TREATMENT OF CLOSED OR OPEN INTERCONDYLAR SPI     N     3
                      27540    7                      OPEN TREATMENT OF CLOSED OR OPEN INTERCONDYLAR SPI     N     3
                      27540    8                      OPEN TREATMENT OF CLOSED OR OPEN INTERCONDYLAR SPI     N     3
                      27550    2                      TREATMENT OF CLOSED KNEE DISLOCATION; WITHOUT ANES     N     3
                      27550    7                      TREATMENT OF CLOSED KNEE DISLOCATION; WITHOUT ANES     N     3
                      27550    F                      TREATMENT OF CLOSED KNEE DISLOCATION; WITHOUT ANES     N     3
                      27552    2                      TREATMENT OF CLOSED KNEE DISLOCATION; REQUIRING AN     N     3
                      27552    7                      TREATMENT OF CLOSED KNEE DISLOCATION; REQUIRING AN     N     3
                      27552    F                      TREATMENT OF CLOSED KNEE DISLOCATION; REQUIRING AN     N     3
                      27556    2                      OPEN TRT OF CLSD/OPEN KNEE DISLOC, W OR W/O INTER/     N     3
                      27556    7                      OPEN TRT OF CLSD/OPEN KNEE DISLOC, W OR W/O INTER/     N     3
                      27556    8                      OPEN TRT OF CLSD/OPEN KNEE DISLOC, W OR W/O INTER/     N     3
                      27557    7                      OPEN TRT OF CLSD/OPEN KNEE DISLOC, W OR W/O INTER/     N     3
                      27558    2                      OPEN TREATMENT OF KNEE DISLOCATION, WITH OR WITHOU     N     3
                      27558    7                      OPEN TRTMT OF KNEE DISLOCATION W/WO INTERNAL           N     3
                      27560    2                      TREATMENT OF CLOSED PATELLAR DISLOCATION; WITHOUT      N     3
                      27560    7                      TREATMENT OF CLOSED PATELLAR DISLOCATION; WITHOUT      N     3
                      27560    F                      TREATMENT OF CLOSED PATELLAR DISLOCATION; WITHOUT      N     3
                      27562    2                      TREATMENT OF CLOSED PATELLAR DISLOCATION; REQUIRIN     N     3
                      27562    7                      TREATMENT OF CLOSED PATELLAR DISLOCATION; REQUIRIN     N     3
                      27562    F                      TREATMENT OF CLOSED PATELLAR DISLOCATION; REQUIRIN     N     3
                      27566    2                      OPEN TREATMENT OF CLOSED OR OPEN PATELLAR DISLOC,      N     3
                      27566    7                      OPEN TREATMENT OF CLOSED OR OPEN PATELLAR DISLOC,      N     3
                      27566    8                      OPEN TREATMENT OF CLOSED OR OPEN PATELLAR DISLOC,      N     3




Updated: 09/22/2006                                                                                                     Page: 96 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      27566    F                      OPEN TREATMENT OF CLOSED OR OPEN PATELLAR DISLOC,      N     3
                      27570    2                      MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESI     N     3
                      27570    7                      MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESI     N     3
                      27570    F                      MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESI     N     3
                      27580    2                      FUSION OF KNEE, ANY TECHNIQUE                          N     3
                      27580    7                      FUSION OF KNEE, ANY TECHNIQUE                          N     3
                      27580    8                      FUSION OF KNEE, ANY TECHNIQUE                          N     3
                      27590    2                      AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL;           N     3
                      27590    7                      AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL;           N     3
                      27590    8                      AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL;           N     3
                      27591    2                      AMPUTATION, THIGH                                      N     3
                      27591    7                      AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; IMMED     N     3
                      27591    8                      AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; IMMED     N     3
                      27592    2                      AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; OPEN,     N     3
                      27592    7                      AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; OPEN,     N     3
                      27592    8                      AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; OPEN,     N     3
                      27594    2                      AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; SECON     N     3
                      27594    7                      AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; SECON     N     3
                      27594    F                      AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; SECON     N     3
                      27596    2                      AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; REAMP     N     3
                      27596    7                      AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; REAMP     N     3
                      27596    8                      AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; REAMP     N     3
                      27598    2                      DISARTICULATION AT KNEE                                N     3
                      27598    7                      DISARTICULATION AT KNEE                                N     3
                      27598    8                      DISARTICULATION AT KNEE                                N     3
                      27599    7                      UNLISTED PROCEDURE, FEMUR OR KNEE                      N     3
                      27600    2                      FASCIOTOMY, LEG, ANTERIOR COMPARTMENT, FOR CLOSED      N     3
                      27600    7                      FASCIOTOMY, LEG, ANTERIOR COMPARTMENT, FOR CLOSED      N     3
                      27600    8                      FASCIOTOMY, LEG, ANTERIOR COMPARTMENT, FOR CLOSED      N     3
                      27600    F                      FASCIOTOMY, LEG, ANTERIOR COMPARTMENT, FOR CLOSED      N     3
                      27601    2                      FASCIOTOMY,LEG, CLOSED SPACE DECOMPRESS/POSTERIOR      N     3
                      27601    8                      FASCIOTOMY,LEG, CLOSED SPACE DECOMPRESS/POSTERIOR      N     3
                      27601    F                      FASCIOTOMY,LEG, CLOSED SPACE DECOMPRESS/POSTERIOR      N     3
                      27602    2                      FASCIOTOMY, LEG, ANT.COMPARTMENT, FOR CLSD SP DECO     N     3
                      27602    7                      FASCIOTOMY, LEG, ANT.COMPARTMENT, FOR CLSD SP DECO     N     3
                      27602    8                      FASCIOTOMY, LEG, ANT.COMPARTMENT, FOR CLSD SP DECO     N     3
                      27602    F                      FASCIOTOMY, LEG, ANT.COMPARTMENT, FOR CLSD SP DECO     N     3
                      27603    2                      INCISION AND DRAINAGE; DEEP ABSCESS OR HEMATOMA        N     3
                      27603    7                      INCISION AND DRAINAGE; DEEP ABSCESS OR HEMATOMA        N     3
                      27603    F                      INCISION AND DRAINAGE; DEEP ABSCESS OR HEMATOMA        N     3
                      27604    7                      INCISION AND DRAINAGE; INFECTED BURSA                  N     3
                      27604    F                      INCISION AND DRAINAGE; INFECTED BURSA                  N     3
                      27605    2                      TENOTOMY, ACHILLES TENDON, SUBCUTANEOUS (SEPARATE      N     3
                      27605    7                      TENOTOMY ACH TEND SUBCU SEP PROC                       N     3
                      27605    F                      TENOTOMY, ACHILLES TENDON, SUBCUTANEOUS (SEPARATE      N     3
                      27606    2                      TENOTOMY,ACHILLES TENDON, SUBCUTANEOUS(SEPARATE        N     3
                      27606    7                      TENOTOMY, ACHILLES TENDON, SUBCUTANEOUS (SEPARATE      N     3




Updated: 09/22/2006                                                                                                     Page: 97 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      27606    F                      TENOTOMY,ACHILLES TENDON, SUBCUTANEOUS(SEPARATE        N     3
                      27607    2                      INCISION, DEEP, WITH OPENING OF BONE CORTEX FOR OS     N     3
                      27607    7                      INCISION, DEEP, WITH OPENING OF BONE CORTEX FOR OS     N     3
                      27607    F                      INCISION, DEEP, WITH OPENING OF BONE CORTEX FOR OS     N     3
                      27608    7                      INCISION, DEEP, WITH OPENING OF BONE CORTEX FOR OS     N     3
                      27610    2                      ARTHROTOMY, ANKLE, WITH EXPLORATION, DRAINAGE OR R     N     3
                      27610    7                      ARTHROTOMY, ANKLE, WITH EXPLORATION, DRAINAGE OR R     N     3
                      27610    8                      ARTHROTOMY, ANKLE, WITH EXPLORATION, DRAINAGE OR R     N     3
                      27610    F                      ARTHROTOMY, ANKLE, WITH EXPLORATION, DRAINAGE OR R     N     3
                      27611    7                      ARTHROTOMY, ANKLE, WITH EXPLOR, DRAIN OR REMOVAL O     N     3
                      27612    2                      ARTHROTOMY, ANKLE, POSTERIOR CAPSULAR RELEASE, W O     N     3
                      27612    7                      ARTHROTOMY, ANKLE, POSTERIOR CAPSULAR RELEASE, W O     N     3
                      27612    8                      ARTHROTOMY, ANKLE, POSTERIOR CAPSULAR RELEASE, W O     N     3
                      27612    F                      ARTHROTOMY, ANKLE, POSTERIOR CAPSULAR RELEASE, W O     N     3
                      27613    2                      BIOPSY, SOFT TISSUES; SUPERFICIAL                      N     3
                      27614    2                      BIOPSY, SOFT TISSUES; DEEP                             N     3
                      27614    7                      BIOPSY SOFT TISSUE DEEP                                N     3
                      27614    F                      BIOPSY, SOFT TISSUES; DEEP                             N     3
                      27615    2                      RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM     N     3
                      27615    7                      RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM     N     3
                      27615    F                      RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM     N     3
                      27618    2                      EXCISION, BENIGN TUMOR; SUBCUTANEOUS                   N     3
                      27618    7                      ANESTHESIA, EXCISION BENIGN TUMOR, SUBCUTANEOUS        N     3
                      27618    F                      EXCISION, BENIGN TUMOR; SUBCUTANEOUS                   N     3
                      27619    2                      EXCISION, BENIGN TUMOR; DEEP SUBFASCIAL OR INTRAMU     N     3
                      27619    7                      EXCISION, BENIGN TUMOR; DEEP SUBFASCIAL OR INTRAMU     N     3
                      27619    F                      EXCISION, BENIGN TUMOR; DEEP SUBFASCIAL OR INTRAMU     N     3
                      27620    2                      ARTHROTOMY, ANKLE, FOR BIOPSY                          N     3
                      27620    7                      ARTHROTOMY, ANKLE, FOR BIOPSY                          N     3
                      27620    F                      ARTHROTOMY, ANKLE, FOR BIOPSY                          N     3
                      27625    2                      ARTHROTOMY, ANKLE, FOR SYNOVECTOMY;                    N     3
                      27625    7                      ARTHROTOMY, ANKLE, FOR SYNOVECTOMY;                    N     3
                      27625    8                      ARTHROTOMY, ANKLE, FOR SYNOVECTOMY;                    N     3
                      27625    F                      ARTHROTOMY, ANKLE, FOR SYNOVECTOMY;                    N     3
                      27626    7                      ARTHROTOMY, ANKLE, FOR SYNOVECTOMY; INCLUDING TENO     N     3
                      27626    F                      ARTHROTOMY, ANKLE, FOR SYNOVECTOMY; INCLUDING TENO     N     3
                      27630    2                      EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG     N     3
                      27630    7                      EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG     N     3
                      27630    8                      EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG     N     3
                      27630    F                      EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG     N     3
                      27635    2                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      27635    7                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      27635    8                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      27635    F                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      27637    2                      EXCIS/CURET OF BONE CYST/BENIGN TUMOR, TIBIA OR FI     N     3
                      27637    7                      EXCIS/CURET OF BONE CYST/BENIGN TUMOR, TIBIA OR FI     N     3
                      27637    8                      EXCIS/CURET OF BONE CYST/BENIGN TUMOR, TIBIA OR FI     N     3




Updated: 09/22/2006                                                                                                     Page: 98 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      27637    F                      EXCIS/CURET OF BONE CYST/BENIGN TUMOR, TIBIA OR FI     N     3
                      27638    2                      EXCIS/CURETT OF BONE CYST/BENIGN TUMOR, TIBIA OR F     N     3
                      27638    7                      EXCIS/CURETT OF BONE CYST/BENIGN TUMOR, TIBIA OR F     N     3
                      27638    8                      EXCIS/CURETT OF BONE CYST/BENIGN TUMOR, TIBIA OR F     N     3
                      27638    F                      EXCIS/CURETT OF BONE CYST/BENIGN TUMOR, TIBIA OR F     N     3
                      27640    2                      PARTIAL EXCISION (CRATERIZATION, SAUCERIZ. OR DIAP     N     3
                      27640    7                      PARTIAL EXCISION (CRATERIZATION, SAUCERIZ. OR DIAP     N     3
                      27640    8                      PARTIAL EXCISION (CRATERIZATION, SAUCERIZ. OR DIAP     N     3
                      27640    F                      PARTIAL EXCISION (CRATERIZATION, SAUCERIZ. OR DIAP     N     3
                      27641    2                      PARTIAL EXCISION (CRATERIZATION, SAUCERIZ. OR DIAP     N     3
                      27641    7                      PARTIAL EXCISION (CRATERIZATION, SAUCERIZ. OR DIAP     N     3
                      27641    8                      PARTIAL EXCISION (CRATERIZATION, SAUCERIZ. OR DIAP     N     3
                      27641    F                      PARTIAL EXCISION (CRATERIZATION, SAUCERIZ. OR DIAP     N     3
                      27645    7                      RESECTION FOR TUMOR, RADICAL; TIBIA                    N     3
                      27646    7                      RESECTION FOR TUMOR, RADICAL; FIBULA                   N     3
                      27647    7                      RESECTION FOR TUMOR, RADICAL; TALUS OR CALCANEUS       N     3
                      27647    F                      RESECTION FOR TUMOR, RADICAL; TALUS OR CALCANEUS       N     3
                      27648    2                      INJECTION PROCEDURE FOR ANKLE ARTHROGRAPHY             N     3
                      27650    2                      SUTURE, PRIMARY, RUPTURED ACHILLES TENDON;             N     3
                      27650    7                      SUTURE, PRIMARY, RUPTURED ACHILLES TENDON;             N     3
                      27650    8                      SUTURE, PRIMARY, RUPTURED ACHILLES TENDON;             N     3
                      27650    F                      SUTURE, PRIMARY, RUPTURED ACHILLES TENDON;             N     3
                      27652    2                      SUTURE, PRIMARY, RUPTURED ACHILLES TENDON; WITH GR     N     3
                      27652    7                      SUTURE, PRIMARY, RUPTURED ACHILLES TENDON; WITH GR     N     3
                      27652    8                      SUTURE, PRIMARY, RUPTURED ACHILLES TENDON; WITH GR     N     3
                      27652    F                      SUTURE, PRIMARY, RUPTURED ACHILLES TENDON; WITH GR     N     3
                      27654    7                      SUTURE, SECONDARY, RUPTURED ACHILLES TENDON, WITH      N     3
                      27654    F                      SUTURE, SECONDARY, RUPTURED ACHILLES TENDON, WITH      N     3
                      27656    2                      REPAIR, FASCIAL DEFECT OF LEG                          N     3
                      27656    7                      REPAIR, FASCIAL DEFECT OF LEG                          N     3
                      27656    F                      REPAIR, FASCIAL DEFECT OF LEG                          N     3
                      27658    2                      REPAIR OR SUTURE OF FLEXOR TENDON OF LEG; PRIMARY,     N     3
                      27658    7                      REPAIR OR SUTURE OF FLEXOR TENDON OF LEG; PRIMARY,     N     3
                      27658    F                      REPAIR OR SUTURE OF FLEXOR TENDON OF LEG; PRIMARY,     N     3
                      27659    2                      REPAIR OR SUTURE OF FLEXOR TENDON OF LEG; SECONDAR     N     3
                      27659    7                      REPAIR OR SUTURE OF FLEXOR TENDON OF LEG; SECONDAR     N     3
                      27659    F                      REPAIR OR SUTURE OF FLEXOR TENDON OF LEG; SECONDAR     N     3
                      27664    2                      REPAIR OR SUTURE OF EXTENSOR TENDON OF LEG; PRIMAR     N     3
                      27664    7                      REPAIR OR SUTURE OF EXTENSOR TENDON OF LEG; PRIMAR     N     3
                      27664    F                      REPAIR OR SUTURE OF EXTENSOR TENDON OF LEG; PRIMAR     N     3
                      27665    2                      REPAIR OR SUTURE OF EXTENSOR TENDON OF LEG; SECOND     N     3
                      27665    7                      REPAIR OF SUT OF EXT TEND OF LEG SINGLE TEND           N     3
                      27665    F                      REPAIR OR SUTURE OF EXTENSOR TENDON OF LEG; SECOND     N     3
                      27675    2                      REPAIR FOR DISLOCATING PERONEAL TENDONS; WITHOUT F     N     3
                      27675    7                      REPAIR FOR DISLOCATING PERONEAL TENDONS; WITHOUT F     N     3
                      27675    F                      REPAIR FOR DISLOCATING PERONEAL TENDONS; WITHOUT F     N     3
                      27676    2                      REPAIR FOR DISLOCATING PERONEAL TENDONS; WITH FIBU     N     3




Updated: 09/22/2006                                                                                                     Page: 99 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                             PA IND PAC
                      27676    7                      REPAIR FOR DISLOCATING PERONEAL TENDONS; WITH FIBU                  N     3
                      27676    8                      REPAIR FOR DISLOCATING PERONEAL TENDONS; WITH FIBU                  N     3
                      27676    F                      REPAIR FOR DISLOCATING PERONEAL TENDONS; WITH FIBU                  N     3
                      27680    2                      TENOLYSIS, INCLUDING TIBIA, FIBULA AND ANKLE FLEXO                  N     3
                      27680    7                      TENOLYSIS, INCLUDING TIBIA, FIBULA AND ANKLE FLEXO                  N     3
                      27680    F                      TENOLYSIS, INCLUDING TIBIA, FIBULA AND ANKLE FLEXO                  N     3
                      27681    2                      TENOLYSIS, INCLUDING TIBIA, FIBULA AND ANKLE FLEXO                  N     3
                      27681    7                      TENOLYSIS, INCLUDING TIBIA, FIBULA AND ANKLE FLEXO                  N     3
                      27681    F                      TENOLYSIS, INCLUDING TIBIA, FIBULA AND ANKLE FLEXO                  N     3
                      27685    2                      LENGTHENING OR SHORTENING OF TENDON; SINGLE (SEPAR                  N     3
                      27685    7                      LENGTHENING OR SHORTENING OF TENDON; SINGLE (SEPAR                  N     3
                      27685    8                      LENGTHENING OR SHORTENING OF TENDON; SINGLE (SEPAR                  N     3
                      27685    F                      LENGTHENING OR SHORTENING OF TENDON; SINGLE (SEPAR                  N     3
                      27686    2                      LENGTHENING OR SHORTENING OF TENDON; MULTIPLE, THR                  N     3
                      27686    7                      LENGTHENING OR SHORTENING OF TENDON; MULTIPLE, THR                  N     3
                      27686    8                      LENGTHENING OR SHORTENING OF TENDON; MULTIPLE, THR                  N     3
                      27686    F                      LENGTHENING OR SHORTENING OF TENDON; MULTIPLE, THR                  N     3
                      27687    2                      GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)                     N     3
                      27687    7                      GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)                     N     3
                      27687    8                      GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)                     N     3
                      27687    F                      GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)                     N     3
                      27690    2                      TRANSFER/TRANSPL OF SINGL TENDON(W/MUSCLE REDIR/RE                  N     3
                      27690    7                      TRANSFER/TRANSPL OF SINGL TENDON(W/MUSCLE REDIR/RE                  N     3
                      27690    8                      TRANSFER/TRANSPL OF SINGL TENDON(W/MUSCLE REDIR/RE                  N     3
                      27690    F                      TRANSFER/TRANSPL OF SINGL TENDON(W/MUSCLE REDIR/RE                  N     3
                      27691    2                      FLEXOR HALLICUS, LONGUS, OR PERONEAL TENDON TO MIDFOOT/HINDFOOT     N     3
                      27691    7                      TRANSF/TRANSPL SINGL TEN(W/MUSCLE REDIR/REROUT);AN                  N     3
                      27691    8                      TRANSF/TRANSPL SINGL TEN(W/MUSCLE REDIR/REROUT);AN                  N     3
                      27691    F                      FLEXOR HALLICUS, LONGUS, OR PERONEAL TENDON TO MIDFOOT/HINDFOOT     N     3
                      27692    2                      TRANSF/TRANSPL SINGL TEN(W/MUSC REDIR/REROUT); ANT                  N     3
                      27692    7                      TRANSF/TRANSPL SINGL TEN(W/MUSC REDIR/REROUT); ANT                  N     3
                      27692    F                      TRANSF/TRANSPL SINGL TEN(W/MUSC REDIR/REROUT); ANT                  N     3
                      27695    2                      SUTURE, PRIMARY, TORN, RUPTURED OR SEVERED LIGAMEN                  N     3
                      27695    7                      SUTURE, PRIMARY, TORN, RUPTURED OR SEVERED LIGAMEN                  N     3
                      27695    8                      SUTURE, PRIMARY, TORN, RUPTURED OR SEVERED LIGAMEN                  N     3
                      27695    F                      SUTURE, PRIMARY, TORN, RUPTURED OR SEVERED LIGAMEN                  N     3
                      27696    2                      SUTURE, PRIMARY, TORN, RUPTURED OR SEVERED LIGAMEN                  N     3
                      27696    7                      SUTURE, PRIMARY, TORN, RUPTURED OR SEVERED LIGAMEN                  N     3
                      27696    8                      SUTURE, PRIMARY, TORN, RUPTURED OR SEVERED LIGAMEN                  N     3
                      27696    F                      SUTURE, PRIMARY, TORN, RUPTURED OR SEVERED LIGAMEN                  N     3
                      27698    2                      SUTURE,SECONDARY REPAIR,TORN,RUPT OR SEVERED LIG,                   N     3
                      27698    7                      SUTURE,SECONDARY REPAIR,TORN,RUPT OR SEVERED LIG,                   N     3
                      27698    8                      SUTURE,SECONDARY REPAIR,TORN,RUPT OR SEVERED LIG,                   N     3
                      27698    F                      SUTURE,SECONDARY REPAIR,TORN,RUPT OR SEVERED LIG,                   N     3
                      27700    2                      ARTHROPLASTY, ANKLE;                                                N     3
                      27700    7                      ARTHROPLASTY, ANKLE;                                                N     3
                      27700    8                      ARTHROPLASTY, ANKLE;                                                N     3




Updated: 09/22/2006                                                                                                                  Page: 100 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      27700    F                      ARTHROPLASTY, ANKLE;                                   N     3
                      27702    7                      ARTHROPLASTY, ANKLE; WITH IMPLANT ("TOTAL ANKLE")      N     3
                      27703    7                      ARTHROPLASTY, ANKLE                                    N     3
                      27704    7                      REMOVAL OF ANKLE IMPLANT                               N     3
                      27704    F                      REMOVAL OF ANKLE IMPLANT                               N     3
                      27705    2                      OSTEOTOMY; TIBIA                                       N     3
                      27705    7                      OSTEOTOMY; TIBIA                                       N     3
                      27705    8                      OSTEOTOMY; TIBIA                                       N     3
                      27705    F                      OSTEOTOMY; TIBIA                                       N     3
                      27707    2                      OSTEOTOMY; FIBULA                                      N     3
                      27707    7                      OSTEOTOMY; FIBULA                                      N     3
                      27707    F                      OSTEOTOMY; FIBULA                                      N     3
                      27709    2                      OSTEOTOMY; TIBIA AND FIBULA                            N     3
                      27709    7                      OSTEOTOMY; TIBIA AND FIBULA                            N     3
                      27709    8                      OSTEOTOMY; TIBIA AND FIBULA                            N     3
                      27709    F                      OSTEOTOMY; TIBIA AND FIBULA                            N     3
                      27712    2                      OSTEOTOMY; MULTIPLE, W/REALIGNMENT ON INTRAMEDULLA     N     3
                      27712    7                      OSTEOTOMY; MULTIPLE, W/REALIGNMENT ON INTRAMEDULLA     N     3
                      27712    8                      OSTEOTOMY; MULTIPLE, W/REALIGNMENT ON INTRAMEDULLA     N     3
                      27715    7                      OSTEOPLASTY, TIBIA AND FIBULA, LENGTHENING             N     3
                      27720    2                      REPAIR OF NONUNION OR MALUNION, TIBIA; W/O GRAFT (     N     3
                      27720    7                      REPAIR OF NONUNION OR MALUNION, TIBIA; W/O GRAFT (     N     3
                      27720    8                      REPAIR OF NONUNION OR MALUNION, TIBIA; W/O GRAFT (     N     3
                      27722    2                      REPAIR OF NONUNION OR MALUNION, TIBIA; WITH SLIDIN     N     3
                      27722    7                      REPAIR OF NONUNION OR MALUNION, TIBIA; WITH SLIDIN     N     3
                      27722    8                      REPAIR OF NONUNION OR MALUNION, TIBIA; WITH SLIDIN     N     3
                      27724    2                      REPAIR OF NONUNION OR MALUNION, TIBIA; W/ ILIAC OR     N     3
                      27724    7                      REPAIR OF NONUNION OR MALUNION, TIBIA; W/ ILIAC OR     N     3
                      27724    8                      REPAIR OF NONUNION OR MALUNION, TIBIA; W/ ILIAC OR     N     3
                      27725    7                      REPAIR OF NONUNION OR MALUNION, TIBIA; BY SYNOSTOS     N     3
                      27727    7                      REPAIR OF CONGENITAL PSEUDARTHROSIS, TIBIA             N     3
                      27730    2                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; D     N     3
                      27730    7                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; D     N     3
                      27730    8                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; D     N     3
                      27730    F                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; D     N     3
                      27732    2                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; D     N     3
                      27732    7                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; D     N     3
                      27732    8                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; D     N     3
                      27732    F                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; D     N     3
                      27734    2                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; D     N     3
                      27734    7                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; D     N     3
                      27734    8                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; D     N     3
                      27734    F                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; D     N     3
                      27740    2                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS/STAPLING, COMB     N     3
                      27740    7                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS/STAPLING, COMB     N     3
                      27740    8                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS/STAPLING, COMB     N     3
                      27740    F                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS/STAPLING, COMB     N     3




Updated: 09/22/2006                                                                                                     Page: 101 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      27742    2                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS/STAPLING, COMB                    N     3
                      27742    7                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS/STAPLING, COMB                    N     3
                      27742    8                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS/STAPLING, COMB                    N     3
                      27742    F                      EPIPHYSEAL ARREST BY EPIPHYSIODESIS/STAPLING, COMB                    N     3
                      27745    7                      PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING                     N     3
                      27745    F                      PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING                     N     3
                      27750    2                      TREATMENT OF CLOSED TIBIAL SHAFT FRACTURE; WITHOUT                    N     3
                      27750    7                      TREATMENT OF CLOSED TIBIAL SHAFT FRACTURE; WITHOUT                    N     3
                      27750    F                      TREATMENT OF CLOSED TIBIAL SHAFT FRACTURE; WITHOUT                    N     3
                      27752    2                      TREATMENT OF CLOSED TIBIAL SHAFT FRACTURE; WITH MA                    N     3
                      27752    7                      TREATMENT OF CLOSED TIBIAL SHAFT FRACTURE; WITH MA                    N     3
                      27752    F                      TREATMENT OF CLOSED TIBIAL SHAFT FRACTURE; WITH MA                    N     3
                      27756    2                      OPEN TREATMENT OF CLOSED OR OPEN TIBIAL SHAFT FX,                     N     3
                      27756    7                      OPEN TREATMENT OF CLOSED OR OPEN TIBIAL SHAFT FX,                     N     3
                      27756    8                      OPEN TREATMENT OF CLOSED OR OPEN TIBIAL SHAFT FX,                     N     3
                      27756    F                      OPEN TREATMENT OF CLOSED OR OPEN TIBIAL SHAFT FX,                     N     3
                      27758    2                      OPEN TREATMENT OF CLOSED OR OPEN TIBIAL SHAFT FX,                     N     3
                      27758    7                      OPEN TREATMENT OF CLOSED OR OPEN TIBIAL SHAFT FX,                     N     3
                      27758    8                      OPEN TREATMENT OF CLOSED OR OPEN TIBIAL SHAFT FX,                     N     3
                      27758    F                      OPEN TREATMENT OF CLOSED OR OPEN TIBIAL SHAFT FX,                     N     3
                      27759    2                      OPEN TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR W                    N     3
                      27759    7                      OPEN TRTMT OF TIBIAL SHAFT FX W/WO FIBULAR                            N     3
                      27759    8                      OPEN TRTMT OF TIBIAL SHAFT FX W/WO FIBULAR                            N     3
                      27759    F                      OPEN TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR W                    N     3
                      27760    2                      TREATMENT OF CLOSED DISTAL TIBIAL FX (MEDIAL MALLE                    N     3
                      27760    7                      TREATMENT OF CLOSED DISTAL TIBIAL FX (MEDIAL MALLE                    N     3
                      27760    F                      TREATMENT OF CLOSED DISTAL TIBIAL FX (MEDIAL MALLE                    N     3
                      27762    2                      TREATMENT OF CLOSED DISTAL TIBIAL FX (MEDIAL MALLE                    N     3
                      27762    7                      TREATMENT OF CLOSED DISTAL TIBIAL FX (MEDIAL MALLE                    N     3
                      27762    F                      TREATMENT OF CLOSED DISTAL TIBIAL FX (MEDIAL MALLE                    N     3
                      27766    2                      OPEN TREAT OF CLOSED OR OPEN DISTAL TIBIAL FX(MEDI                    N     3
                      27766    7                      OPEN TREAT OF CLOSED OR OPEN DISTAL TIBIAL FX(MEDI                    N     3
                      27766    8                      OPEN TREAT OF CLOSED OR OPEN DISTAL TIBIAL FX(MEDI                    N     3
                      27766    F                      OPEN TREAT OF CLOSED OR OPEN DISTAL TIBIAL FX(MEDI                    N     3
                      27780    2                      TREATMENT OF CLOSED PROXIMAL FIBULA OR SHAFT FX, W                    N     3
                      27780    7                      TREATMENT OF CLOSED PROXIMAL FIBULA OR SHAFT FX, W                    N     3
                      27780    F                      TREATMENT OF CLOSED PROXIMAL FIBULA OR SHAFT FX, W                    N     3
                      27781    2                      TREATMENT OF CLOSED PROXIMAL FIBULA OR SHAFT FX, W                    N     3
                      27781    7                      TREATMENT OF CLOSED PROXIMAL FIBULA OR SHAFT FX, W                    N     3
                      27781    F                      TREATMENT OF CLOSED PROXIMAL FIBULA OR SHAFT FX, W                    N     3
                      27784    2                      OPEN TREAT OF CLOSED OR OPEN PROX FIB OR SHAFT FX,                    N     3
                      27784    7                      OPEN TREAT OF CLOSED OR OPEN PROX FIB OR SHAFT FX,                    N     3
                      27784    8                      OPEN TREAT OF CLOSED OR OPEN PROX FIB OR SHAFT FX,                    N     3
                      27784    F                      OPEN TREAT OF CLOSED OR OPEN PROX FIB OR SHAFT FX,                    N     3
                      27786    2                      CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS WO     N     3
                      27786    7                      TREAT OF CLOSED DISTAL FIBULAR FX (LATERAL MALLEOL                    N     3
                      27786    F                      CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS WO     N     3




Updated: 09/22/2006                                                                                                                    Page: 102 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      27788    2                      TREAT OF CLOSED DISTAL FIBULAR FX (LATERAL MALLEOL     N     3
                      27788    7                      TREAT OF CLOSED DISTAL FIBULAR FX (LATERAL MALLEOL     N     3
                      27788    F                      TREAT OF CLOSED DISTAL FIBULAR FX (LATERAL MALLEOL     N     3
                      27792    2                      OPEN TREAT OF CLOSED OR OPEN DISTAL FIB FX (LATERA     N     3
                      27792    7                      OPEN TREAT OF CLOSED OR OPEN DISTAL FIB FX (LATERA     N     3
                      27792    8                      OPEN TREAT OF CLOSED OR OPEN DISTAL FIB FX (LATERA     N     3
                      27792    F                      OPEN TREAT OF CLOSED OR OPEN DISTAL FIB FX (LATERA     N     3
                      27808    2                      TREATMENT OF CLOSED BIMALLEOLAR ANKLE FX,(INCLUD P     N     3
                      27808    7                      TREATMENT OF CLOSED BIMALLEOLAR ANKLE FX,(INCLUD P     N     3
                      27808    F                      TREATMENT OF CLOSED BIMALLEOLAR ANKLE FX,(INCLUD P     N     3
                      27810    2                      TREATMENT OF CLOSED BIMALLEOLAR ANKLE FX,(INCLUD P     N     3
                      27810    7                      TREATMENT OF CLOSED BIMALLEOLAR ANKLE FX,(INCLUD P     N     3
                      27810    F                      TREATMENT OF CLOSED BIMALLEOLAR ANKLE FX,(INCLUD P     N     3
                      27814    2                      OPEN TREATMENT OF CLOSED OR OPEN BIMALLEOLAR ANKLE     N     3
                      27814    7                      OPEN TREATMENT OF CLOSED OR OPEN BIMALLEOLAR ANKLE     N     3
                      27814    8                      OPEN TREATMENT OF CLOSED OR OPEN BIMALLEOLAR ANKLE     N     3
                      27814    F                      OPEN TREATMENT OF CLOSED OR OPEN BIMALLEOLAR ANKLE     N     3
                      27816    2                      TREATMENT OF CLOSED TRIMALLEOLAR ANKLE FRACTURE; W     N     3
                      27816    7                      TREATMENT OF CLOSED TRIMALLEOLAR ANKLE FRACTURE; W     N     3
                      27816    F                      TREATMENT OF CLOSED TRIMALLEOLAR ANKLE FRACTURE; W     N     3
                      27818    2                      TREATMENT OF CLOSED TRIMALLEOLAR ANKLE FRACTURE; W     N     3
                      27818    7                      TREATMENT OF CLOSED TRIMALLEOLAR ANKLE FRACTURE; W     N     3
                      27818    F                      TREATMENT OF CLOSED TRIMALLEOLAR ANKLE FRACTURE; W     N     3
                      27822    2                      OPEN TREAT OF CLSD OR OPN TRIMA ANKLE FX, W OR W/O     N     3
                      27822    7                      OPEN TREAT OF CLSD OR OPN TRIMA ANKLE FX, W OR W/O     N     3
                      27822    8                      OPEN TREAT OF CLSD OR OPN TRIMA ANKLE FX, W OR W/O     N     3
                      27822    F                      OPEN TREAT OF CLSD OR OPN TRIMA ANKLE FX, W OR W/O     N     3
                      27823    2                      OPN TRT, CLSD/OPN TRI ANK FX,W OR W/O INT-EXT FIX,     N     3
                      27823    7                      OPN TRT, CLSD/OPN TRI ANK FX,W OR W/O INT-EXT FIX,     N     3
                      27823    8                      OPN TRT, CLSD/OPN TRI ANK FX,W OR W/O INT-EXT FIX,     N     3
                      27823    F                      OPN TRT, CLSD/OPN TRI ANK FX,W OR W/O INT-EXT FIX,     N     3
                      27824    2                      CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ART     N     3
                      27824    7                      CLSD TRTMT OF FX WEIGHT BEARING ARTCLR PORTION         N     3
                      27824    F                      CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ART     N     3
                      27825    2                      CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ART     N     3
                      27825    7                      CLSD TRTMT OF FX WEIGHT BEARING ARTCLR PORTION         N     3
                      27825    F                      CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ART     N     3
                      27826    2                      OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTIC     N     3
                      27826    7                      OPEN TRTMT OF FX OF WEIGHT BEARNG ARTICULR SUF FIB     N     3
                      27826    F                      OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTIC     N     3
                      27827    2                      OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTIC     N     3
                      27827    7                      OPEN TRTMT OF FX OF WEIGHT BEARING ARTICUL SURFACE     N     3
                      27827    8                      OPEN TRTMT OF FX OF WEIGHT BEARING ARTICUL SURFACE     N     3
                      27827    F                      OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTIC     N     3
                      27828    2                      OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTIC     N     3
                      27828    7                      OPEN TRTMT FRACTURE OF WEIGHT LEARNING ARTICULAR S     N     3
                      27828    8                      OPEN TRTMT FRACTURE OF WEIGHT LEARNING ARTICULAR S     N     3




Updated: 09/22/2006                                                                                                     Page: 103 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      27828    F                      OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTIC     N     3
                      27829    2                      OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDE     N     3
                      27829    7                      OPEN TRTMT OF DISTAL TIBIOFIBULAR JOINT DISRUPTION     N     3
                      27829    F                      OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDE     N     3
                      27830    7                      TREATMENT OF PROXIMAL TIBIOFIBULAR JOINT DISLOCATI     N     3
                      27830    F                      TREATMENT OF PROXIMAL TIBIOFIBULAR JOINT DISLOCATI     N     3
                      27831    7                      TREATMENT OF PROXIMAL TIBIOFIBULAR JOINT DISLOCATI     N     3
                      27831    F                      TREATMENT OF PROXIMAL TIBIOFIBULAR JOINT DISLOCATI     N     3
                      27832    2                      OPEN TREATMENT OF PROXIMAL TIBIOFIBULAR JOINT DISL     N     3
                      27832    7                      OPEN TREATMENT OF PROXIMAL TIBIOFIBULAR JOINT DISL     N     3
                      27832    F                      OPEN TREATMENT OF PROXIMAL TIBIOFIBULAR JOINT DISL     N     3
                      27840    2                      TREATMENT OF ANKLE DISLOCATION; WITHOUT ANESTHESIA     N     3
                      27840    F                      TREATMENT OF ANKLE DISLOCATION; WITHOUT ANESTHESIA     N     3
                      27842    2                      TREATMENT OF ANKLE DISLOCATION; REQUIRING ANESTHES     N     3
                      27842    7                      TREATMENT OF ANKLE DISLOCATION; REQUIRING ANESTHES     N     3
                      27842    F                      TREATMENT OF ANKLE DISLOCATION; REQUIRING ANESTHES     N     3
                      27846    2                      OPEN TREATMENT OF CLOSED OR OPEN ANKLE DISLOCATION     N     3
                      27846    7                      OPEN TREATMENT OF CLOSED OR OPEN ANKLE DISLOCATION     N     3
                      27846    8                      OPEN TREATMENT OF CLOSED OR OPEN ANKLE DISLOCATION     N     3
                      27846    F                      OPEN TREATMENT OF CLOSED OR OPEN ANKLE DISLOCATION     N     3
                      27848    2                      OPEN TREATMENT OF CLOSED OR OPEN ANKLE DISLOCATION     N     3
                      27848    7                      OPEN TREATMENT OF CLOSED OR OPEN ANKLE DISLOCATION     N     3
                      27848    8                      OPEN TREATMENT OF CLOSED OR OPEN ANKLE DISLOCATION     N     3
                      27848    F                      OPEN TREATMENT OF CLOSED OR OPEN ANKLE DISLOCATION     N     3
                      27851    7                      ANTERIOR TIBIAL TUBERCLE PLASTY FOR CHONDROMALACIA     N     3
                      27860    2                      MANIPULATION OF ANKLE UNDER GENERAL ANESTHESIA (IN     N     3
                      27860    7                      MANIPULATION OF ANKLE UNDER GENERAL ANESTHESIA (IN     N     3
                      27860    F                      MANIPULATION OF ANKLE UNDER GENERAL ANESTHESIA (IN     N     3
                      27870    2                      ARTHRODESIS, ANKLE, ANY METHOD                         N     3
                      27870    7                      ARTHRODESIS, ANKLE, ANY METHOD                         N     3
                      27870    8                      ARTHRODESIS, ANKLE, ANY METHOD                         N     3
                      27870    F                      ARTHRODESIS, ANKLE, ANY METHOD                         N     3
                      27871    7                      ARTHRODESIS, TIBIOFIBULAR JOINT, PROXIMAL OR DISTA     N     3
                      27871    F                      ARTHRODESIS, TIBIOFIBULAR JOINT, PROXIMAL OR DISTA     N     3
                      27880    2                      AMPUTATION LEG, THROUGH TIBIA AND FIBULA;              N     3
                      27880    7                      AMPUTATION LEG, THROUGH TIBIA AND FIBULA;              N     3
                      27880    8                      AMPUTATION LEG, THROUGH TIBIA AND FIBULA;              N     3
                      27881    2                      AMPUTATION LEG                                         N     3
                      27881    7                      AMPUTATION LEG, THROUGH TIBIA AND FIBULA; W/IMMEDI     N     3
                      27881    8                      AMPUTATION LEG, THROUGH TIBIA AND FIBULA; W/IMMEDI     N     3
                      27882    2                      AMPUTATION LEG, THROUGH TIBIA AND FIBULA; OPEN FLA     N     3
                      27882    7                      AMPUTATION LEG, THROUGH TIBIA AND FIBULA; OPEN FLA     N     3
                      27882    8                      AMPUTATION LEG, THROUGH TIBIA AND FIBULA; OPEN FLA     N     3
                      27884    2                      AMPUTATION LEG, THROUGH TIBIA AND FIBULA; SECONDAR     N     3
                      27884    7                      AMPUTATION LEG, THROUGH TIBIA AND FIBULA; SECONDAR     N     3
                      27884    F                      AMPUTATION LEG, THROUGH TIBIA AND FIBULA; SECONDAR     N     3
                      27886    2                      AMPUTATION LEG, THROUGH TIBIA AND FIBULA; REAMPUTA     N     3




Updated: 09/22/2006                                                                                                     Page: 104 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      27886    7                      AMPUTATION LEG, THROUGH TIBIA AND FIBULA; REAMPUTA     N     3
                      27886    8                      AMPUTATION LEG, THROUGH TIBIA AND FIBULA; REAMPUTA     N     3
                      27888    2                      AMPUTAT,ANKLE,THRU MALLEOLI TIBIA & FIBULA(SYME,PI     N     3
                      27888    7                      AMPUTAT,ANKLE,THRU MALLEOLI TIBIA & FIBULA(SYME,PI     N     3
                      27888    8                      AMPUTAT,ANKLE,THRU MALLEOLI TIBIA & FIBULA(SYME,PI     N     3
                      27889    7                      ANKLE DISARTICULATION                                  N     3
                      27889    F                      ANKLE DISARTICULATION                                  N     3
                      27892    2                      DECOMPRESSION FASCIOTOMY, LEG;                         N     3
                      27892    7                      MISCELLANEOUS                                          N     3
                      27892    F                      DECOMPRESSION FASCIOTOMY, LEG;                         N     3
                      27893    2                      DECOMPRESSION FASCIOTOMY, LEG;                         N     3
                      27893    7                      DECOMPRESSION FASCOTOMY, LEG POSTERIOR COMPARTMENT     N     3
                      27893    F                      DECOMPRESSION FASCIOTOMY, LEG;                         N     3
                      27894    2                      DECOMPRESSION FASCIOTOMY, LEG;                         N     3
                      27894    7                      DECOMPRESSION FASCIOTOMY LEG ANTERIOR/LATERAL COMP     N     3
                      27894    F                      DECOMPRESSION FASCIOTOMY, LEG;                         N     3
                      27899    7                      UNLISTED PROCEDURE, LEG OR ANKLE                       N     3
                      28001    2                      INCISION AND DRAINAGE, INFECTED BURSA                  N     3
                      28001    7                      INCISION AND DRAINAGE, INFECTED BURSA - FOOT           N     3
                      28002    2                      DEEP INFECT,BELOW FASC,REQUIR DEEP DISSECT, W OR W     N     3
                      28002    7                      DEEP INFECT,BELOW FASC,REQUIR DEEP DISSECT, W OR W     N     3
                      28002    F                      DEEP INFECT,BELOW FASC,REQUIR DEEP DISSECT, W OR W     N     3
                      28003    2                      DEEP INFECT,BELOW FASC,REQUIR DEEP DISSECT, W OR W     N     3
                      28003    7                      DEEP INFECT,BELOW FASC,REQUIR DEEP DISSECT, W OR W     N     3
                      28003    8                      DEEP INFECT,BELOW FASC,REQUIR DEEP DISSECT, W OR W     N     3
                      28003    F                      DEEP INFECT,BELOW FASC,REQUIR DEEP DISSECT, W OR W     N     3
                      28004    7                      DEEP INFECT,BELOW FASC,REQUIR DEEP DISSECT, W OR W     N     3
                      28005    2                      INCISION, DEEP, WITH OPENING OF BONE CORTEX FOR OS     N     3
                      28005    7                      INCISION, DEEP, WITH OPENING OF BONE CORTEX FOR OS     N     3
                      28005    8                      INCISION, DEEP, WITH OPENING OF BONE CORTEX FOR OS     N     3
                      28005    F                      INCISION, DEEP, WITH OPENING OF BONE CORTEX FOR OS     N     3
                      28006    7                      INCISION, DEEP, WITH OPENING OF BONE CORTEX FOR OS     N     3
                      28008    2                      FASCIOTOMY, PLANTAR AND/OR TOE, SUBCUTANEOUS           N     3
                      28008    7                      FASCIOTOMY, PLANTAR AND/OR TOE, SUBCUTANEOUS           N     3
                      28008    F                      FASCIOTOMY, PLANTAR AND/OR TOE, SUBCUTANEOUS           N     3
                      28010    2                      TENOTOMY, SUBCUTANEOUS, TOE; SINGLE                    N     3
                      28010    7                      TENOTOMY, SUBCUTANEOUS, TOE; SINGLE                    N     3
                      28011    2                      TENOTOMY, SUBCUTANEOUS, TOE; MULTIPLE                  N     3
                      28011    7                      TENOTOMY, SUBCUTANEOUS, TOE; MULTIPLE                  N     3
                      28011    F                      TENOTOMY, SUBCUTANEOUS, TOE; MULTIPLE                  N     3
                      28020    2                      ARTHROTOMY,W/EXPLOR,DRAIN OR REMOV OF LOOSE OR FOR     N     3
                      28020    7                      ARTHROTOMY,W/EXPLOR,DRAIN OR REMOV OF LOOSE OR FOR     N     3
                      28020    F                      ARTHROTOMY,W/EXPLOR,DRAIN OR REMOV OF LOOSE OR FOR     N     3
                      28022    2                      ARTHROTOMY,W/EXPLOR,DRAIN OR REMOV OF LOOSE OR FOR     N     3
                      28022    7                      ARTHROTOMY,W/EXPLOR,DRAIN OR REMOV OF LOOSE OR FOR     N     3
                      28022    F                      ARTHROTOMY,W/EXPLOR,DRAIN OR REMOV OF LOOSE OR FOR     N     3
                      28024    2                      ARTHROTOMY,W/EXPLOR,DRAIN OR REMOV OF LOOSE OR FOR     N     3




Updated: 09/22/2006                                                                                                     Page: 105 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      28024    7                      ARTHROTOMY,W/EXPLOR,DRAIN OR REMOV OF LOOSE OR FOR     N     3
                      28024    F                      ARTHROTOMY,W/EXPLOR,DRAIN OR REMOV OF LOOSE OR FOR     N     3
                      28030    7                      NEURECTOMY OF INTRINSIC MUSCULATURE OF FOOT            N     3
                      28030    F                      NEURECTOMY OF INTRINSIC MUSCULATURE OF FOOT            N     3
                      28035    2                      TARSAL TUNNEL RELEASE (POSTERIOR TIBIAL NERVE DECO     N     3
                      28035    7                      TARSAL TUNNEL RELEASE (POSTERIOR TIBIAL NERVE DECO     N     3
                      28035    8                      TARSAL TUNNEL RELEASE (POSTERIOR TIBIAL NERVE DECO     N     3
                      28035    F                      TARSAL TUNNEL RELEASE (POSTERIOR TIBIAL NERVE DECO     N     3
                      28043    2                      EXCISION, BENIGN TUMOR; SUBCUTANEOUS                   N     3
                      28043    7                      EXCISION, BENIGN TUMOR, SUBCUTANEOUS                   N     3
                      28043    F                      EXCISION, BENIGN TUMOR; SUBCUTANEOUS                   N     3
                      28045    2                      EXCISION, BENIGN TUMOR; DEEP, SUBFASCIAL, INTRAMUS     N     3
                      28045    7                      EXCISION, BENIGN TUMOR; DEEP, SUBFASCIAL, INTRAMUS     N     3
                      28045    8                      EXCISION, BENIGN TUMOR; DEEP, SUBFASCIAL, INTRAMUS     N     3
                      28045    F                      EXCISION, BENIGN TUMOR; DEEP, SUBFASCIAL, INTRAMUS     N     3
                      28046    2                      RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM     N     3
                      28046    7                      RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM     N     3
                      28046    F                      RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM     N     3
                      28050    2                      ARTHROTOMY FOR SYNOVIAL BIOPSY; INTERTARSAL OR TAR     N     3
                      28050    7                      ARTHROTOMY FOR SYNOVIAL BIOPSY; INTERTARSAL OR TAR     N     3
                      28050    F                      ARTHROTOMY FOR SYNOVIAL BIOPSY; INTERTARSAL OR TAR     N     3
                      28052    2                      ARTHROTOMY FOR SYNOVIAL BIOPSY; METATARSOPHALANGEA     N     3
                      28052    7                      ARTHROTOMY FOR SYNOVIAL BIOPSY; METATARSOPHALANGEA     N     3
                      28052    F                      ARTHROTOMY FOR SYNOVIAL BIOPSY; METATARSOPHALANGEA     N     3
                      28054    2                      ARTHROTOMY FOR SYNOVIAL BIOPSY; INTERPHALANGEAL JO     N     3
                      28054    7                      ARTHROTOMY FOR SYNOVIAL BIOPSY; INTERPHALANGEAL JO     N     3
                      28054    F                      ARTHROTOMY FOR SYNOVIAL BIOPSY; INTERPHALANGEAL JO     N     3
                      28060    2                      FASCIECTOMY, EXCISION OF PLANTAR FASCIA; PARTIAL (     N     3
                      28060    7                      FASCIECTOMY, EXCISION OF PLANTAR FASCIA; PARTIAL (     N     3
                      28060    8                      FASCIECTOMY, EXCISION OF PLANTAR FASCIA; PARTIAL (     N     3
                      28060    F                      FASCIECTOMY, EXCISION OF PLANTAR FASCIA; PARTIAL (     N     3
                      28062    7                      FASCIECTOMY, EXCISION OF PLANTAR FASCIA; RADICAL (     N     3
                      28062    F                      FASCIECTOMY, EXCISION OF PLANTAR FASCIA; RADICAL (     N     3
                      28070    2                      SYNOVECTOMY; INTERTARSAL OR TARSOMETATARSAL JOINT,     N     3
                      28070    7                      SYNOVECTOMY; INTERTARSAL OR TARSOMETATARSAL JOINT,     N     3
                      28070    F                      SYNOVECTOMY; INTERTARSAL OR TARSOMETATARSAL JOINT,     N     3
                      28072    2                      SYNOVECTOMY; METATARSOPHALANGEAL JOINT, EACH           N     3
                      28072    7                      SYNOVECTOMY; METATARSOPHALANGEAL JOINT, EACH           N     3
                      28072    F                      SYNOVECTOMY; METATARSOPHALANGEAL JOINT, EACH           N     3
                      28080    2                      EXCISION OF MORTON NEUROMA, SINGLE, EACH               N     3
                      28080    7                      EXCISION OF MORTON NEUROMA, SINGLE, EACH               N     3
                      28080    F                      EXCISION OF MORTON NEUROMA, SINGLE, EACH               N     3
                      28086    7                      SYNOVECTOMY, TENDON SHEATH; FLEXOR                     N     3
                      28086    F                      SYNOVECTOMY, TENDON SHEATH; FLEXOR                     N     3
                      28088    2                      SYNOVECTOMY, TENDON SHEATH; EXTENSOR                   N     3
                      28088    7                      SYNOVECTOMY, TENDON SHEATH; EXTENSOR                   N     3
                      28088    F                      SYNOVECTOMY, TENDON SHEATH; EXTENSOR                   N     3




Updated: 09/22/2006                                                                                                     Page: 106 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      28090    2                      EXCIS OF LESION OF TENDON OR FIBR SHEATH OR CAPSUL     N     3
                      28090    7                      EXCIS OF LESION OF TENDON OR FIBR SHEATH OR CAPSUL     N     3
                      28090    8                      EXCIS OF LESION OF TENDON OR FIBR SHEATH OR CAPSUL     N     3
                      28090    F                      EXCIS OF LESION OF TENDON OR FIBR SHEATH OR CAPSUL     N     3
                      28092    2                      EXCIS OF LESION OF TENDON OR FIBR SHEATH OR CAPSUL     N     3
                      28092    7                      EXCIS OF LESION OF TENDON OR FIBR SHEATH OR CAPSUL     N     3
                      28092    F                      EXCIS OF LESION OF TENDON OR FIBR SHEATH OR CAPSUL     N     3
                      28100    2                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      28100    7                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      28100    F                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      28102    2                      EXCIS OR CURET BONE CYST/BENIGN TUMOR,TALUS/CALCAN     N     3
                      28102    7                      EXCIS/CURET BONE CYST/BENI TUM/TAL/CALC WITH GRAFT     N     3
                      28102    8                      EXCIS OR CURET BONE CYST/BENIGN TUMOR,TALUS OR CAL     N     3
                      28102    F                      EXCIS OR CURET BONE CYST/BENIGN TUMOR,TALUS/CALCAN     N     3
                      28103    7                      EXCIS OR CURET BONE CYST OR BENIGN TUMOR, TALUS OR     N     3
                      28103    F                      EXCIS OR CURET BONE CYST OR BENIGN TUMOR, TALUS OR     N     3
                      28104    2                      EXCIS OR CURET BONE CYST OR BENIGN TUMOR, TARSAL O     N     3
                      28104    7                      EXCIS OR CURET BONE CYST OR BENIGN TUMOR, TARSAL O     N     3
                      28104    F                      EXCIS OR CURET BONE CYST OR BENIGN TUMOR, TARSAL O     N     3
                      28106    2                      EXC/CURET BONE CYST/BENIGN TUM,TARS OR METATAR BON     N     3
                      28106    7                      EXC/CURET BONE CYST/BENIGN TUM,TARS OR METATAR BON     N     3
                      28106    8                      EXC/CURET BONE CYST/BENIGN TUM,TARS OR METATAR BON     N     3
                      28106    F                      EXC/CURET BONE CYST/BENIGN TUM,TARS OR METATAR BON     N     3
                      28107    7                      EXCIS/CURET BONE CYST OR BENIGN TUMOR, TARSAL OR M     N     3
                      28107    F                      EXCIS/CURET BONE CYST OR BENIGN TUMOR, TARSAL OR M     N     3
                      28108    2                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      28108    7                      EXCIS/CURET BONE CYST/BENI TUM/PHALANGES               N     3
                      28109    7                      EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR     N     3
                      28110    2                      OSTECTOMY, PARTIAL EXCISION, FIFTH METATARSAL (BUN     N     3
                      28110    7                      OSTECTOMY, PARTIAL EXCISION, FIFTH METATARSAL (BUN     N     3
                      28110    F                      OSTECTOMY, PARTIAL EXCISION, FIFTH METATARSAL (BUN     N     3
                      28111    2                      OSTECTOMY; COMPLETE EXCISION OF FIRST METATARSAL H     N     3
                      28111    7                      OSTECTOMY; COMPLETE EXCISION OF FIRST METATARSAL H     N     3
                      28111    8                      OSTECTOMY; COMPLETE EXCISION OF FIRST METATARSAL H     N     3
                      28111    F                      OSTECTOMY; COMPLETE EXCISION OF FIRST METATARSAL H     N     3
                      28112    2                      OSTECTOMY; OTHER METATARSAL HEAD (SECOND,THIRD OR      N     3
                      28112    7                      OSTECTOMY; OTHER METATARSAL HEAD (SECOND,THIRD OR      N     3
                      28112    8                      OSTECTOMY; OTHER METATARSAL HEAD (SECOND,THIRD OR      N     3
                      28112    F                      OSTECTOMY; OTHER METATARSAL HEAD (SECOND,THIRD OR      N     3
                      28113    2                      OSTECTOMY; FIFTH METATARSAL HEAD                       N     3
                      28113    7                      OSTECTOMY; FIFTH METATARSAL HEAD                       N     3
                      28113    F                      OSTECTOMY; FIFTH METATARSAL HEAD                       N     3
                      28114    2                      OSTECTOMY; ALL METATARSAL HEADS WITH PARTIAL PROXI     N     3
                      28114    7                      OSTECTOMY; ALL METATARSAL HEADS WITH PARTIAL PROXI     N     3
                      28114    F                      OSTECTOMY; ALL METATARSAL HEADS WITH PARTIAL PROXI     N     3
                      28116    2                      OSTECTOMY, EXCISION OF TARSAL COALITION                N     3
                      28116    7                      OSTECTOMY, EXCISION OF TARSAL COALITION                N     3




Updated: 09/22/2006                                                                                                     Page: 107 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      28116    8                      OSTECTOMY, EXCISION OF TARSAL COALITION                N     3
                      28116    F                      OSTECTOMY, EXCISION OF TARSAL COALITION                N     3
                      28118    2                      OSTECTOMY, CALCANEUS; PARTIAL                          N     3
                      28118    7                      OSTECTOMY, CALCANEUS; PARTIAL                          N     3
                      28118    8                      OSTECTOMY, CALCANEUS; PARTIAL                          N     3
                      28118    F                      OSTECTOMY, CALCANEUS; PARTIAL                          N     3
                      28119    2                      OSTECTOMY, CALCANEUS; FOR SPUR, WITH OR WITHOUT PL     N     3
                      28119    7                      OSTECTOMY, CALCANEUS; FOR SPUR, WITH OR WITHOUT PL     N     3
                      28119    8                      OSTECTOMY, CALCANEUS; FOR SPUR, WITH OR WITHOUT PL     N     3
                      28119    F                      OSTECTOMY, CALCANEUS; FOR SPUR, WITH OR WITHOUT PL     N     3
                      28120    2                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3
                      28120    7                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3
                      28120    8                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3
                      28120    F                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3
                      28121    7                      PARTIAL EXCISION OF BONE (CRATERIZATION, SAUCERIZA     N     3
                      28122    2                      PARTIAL EXCISION OF BONE (CRATERIZATION),TARSAL OR     N     3
                      28122    7                      PARTIAL EXCISION OF BONE (CRATERIZATION),TARSAL OR     N     3
                      28122    8                      PARTIAL EXCISION OF BONE (CRATERIZATION),TARSAL OR     N     3
                      28122    F                      PARTIAL EXCISION OF BONE (CRATERIZATION),TARSAL OR     N     3
                      28123    7                      PARTIAL EXCISION OF BONE (CRATERIZATION),TARSAL OR     N     3
                      28124    2                      PARTIAL EXCISION OF BONE (CRATERIZATION), PHALANX      N     3
                      28124    7                      PARTIAL EXCISION OF BONE (CRATERIZATION), PHALANX      N     3
                      28126    2                      CONDYLECTOMY, PHALANGEAL BASE, SINGLE TOE, EACH        N     3
                      28126    7                      CONDYLECTOMY, PHALANGEAL BASE, SINGLE TOE, EACH        N     3
                      28126    F                      CONDYLECTOMY, PHALANGEAL BASE, SINGLE TOE, EACH        N     3
                      28130    2                      TALECTOMY (ASTRAGALECTOMY)                             N     3
                      28130    7                      TALECTOMY (ASTRAGALECTOMY)                             N     3
                      28130    8                      TALECTOMY (ASTRAGALECTOMY)                             N     3
                      28130    F                      TALECTOMY (ASTRAGALECTOMY)                             N     3
                      28140    2                      METATARSECTOMY                                         N     3
                      28140    7                      METATARSECTOMY                                         N     3
                      28140    F                      METATARSECTOMY                                         N     3
                      28150    2                      PHALANGECTOMY, SINGLE, EACH                            N     3
                      28150    7                      PHALANGECTOMY, SINGLE, EACH                            N     3
                      28150    F                      PHALANGECTOMY, SINGLE, EACH                            N     3
                      28153    2                      RESECTION, HEAD OF PHALANX                             N     3
                      28153    7                      RESECTION, HEAD OF PHALANX                             N     3
                      28153    F                      RESECTION, HEAD OF PHALANX                             N     3
                      28160    2                      HEMIPHALANGECTOMY OR INTERPHALANGEAL JOINT EXCISIO     N     3
                      28160    7                      HEMIPHALANGECTOMY OR INTERPHALANGEAL JOINT EXCISIO     N     3
                      28160    F                      HEMIPHALANGECTOMY OR INTERPHALANGEAL JOINT EXCISIO     N     3
                      28171    7                      RADICAL RESECTION FOR TUMOR TARSAL (EXCEPT TALUS O     N     3
                      28171    F                      RADICAL RESECTION FOR TUMOR TARSAL (EXCEPT TALUS R     N     3
                      28173    7                      RADICAL RESECTION FOR TUMOR METATARSAL (EXCEPT TAL     N     3
                      28175    7                      RADICAL RESECTION FOR TUMOR PHALANX (EXCEPT TALUS      N     3
                      28175    F                      RADICAL RESECTION FOR TUMOR PHALANX (EXCEPT TALUS      N     3
                      28190    2                      REMOVE FOREIGN BODY; SUBCUTANEOUS                      N     3




Updated: 09/22/2006                                                                                                     Page: 108 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      28190    7                      REMOVE FOREIGN BODY SUBCUTANEOUS                       N     3
                      28192    2                      REMOVE FOREIGN BODY; DEEP                              N     3
                      28192    7                      REMOVAL OF FOREIGN BODY FOOT SUBCUTANEOUS DEEP         N     3
                      28192    F                      REMOVE FOREIGN BODY; DEEP                              N     3
                      28193    2                      REMOVE FOREIGN BODY; COMPLICATED                       N     3
                      28193    7                      REMOVE FOREIGN BODY; COMPLICATED                       N     3
                      28193    F                      REMOVE FOREIGN BODY; COMPLICATED                       N     3
                      28200    2                      REPAIR OR SUTURE OF TENDON,FOOT,FLEXOR,SINGLE;PRIM     N     3
                      28200    7                      REPAIR OR SUTURE OF TENDON,FOOT,FLEXOR,SINGLE;PRIM     N     3
                      28200    F                      REPAIR OR SUTURE OF TENDON,FOOT,FLEXOR,SINGLE;PRIM     N     3
                      28202    2                      REPAIR OR SUTURE OF TENDON,FOOT,FLEXOR,SINGLE; SEC     N     3
                      28202    7                      REPAIR OR SUTURE OF TENDON,FOOT,FLEXOR,SINGLE; SEC     N     3
                      28202    F                      REPAIR OR SUTURE OF TENDON,FOOT,FLEXOR,SINGLE; SEC     N     3
                      28208    2                      REPAIR OR SUTURE OF TENDON,FOOT,EXTENSOR,SINGLE; P     N     3
                      28208    7                      REPAIR OR SUTURE OF TENDON,FOOT,EXTENSOR,SINGLE; P     N     3
                      28208    F                      REPAIR OR SUTURE OF TENDON,FOOT,EXTENSOR,SINGLE; P     N     3
                      28210    2                      REPAIR OR SUTURE OF TENDON, FOOT, EXTENSOR, SINGLE     N     3
                      28210    7                      REPAIR OR SUTURE OF TENDON, FOOT, EXTENSOR, SINGLE     N     3
                      28210    F                      REPAIR OR SUTURE OF TENDON, FOOT, EXTENSOR, SINGLE     N     3
                      28220    2                      TENOLYSIS, FLEXOR; SINGLE                              N     3
                      28220    7                      TENOLYSIS, FLEXOR; SINGLE                              N     3
                      28222    2                      TENOLYSIS, FLEXOR; MULTIPLE, EACH                      N     3
                      28222    7                      TENOLYSIS, FLEXOR; MULTIPLE, EACH                      N     3
                      28222    F                      TENOLYSIS, FLEXOR; MULTIPLE, EACH                      N     3
                      28225    2                      TENOLYSIS, EXTENSOR; SINGLE                            N     3
                      28225    7                      TENOLYSIS, EXTENSOR; SINGLE                            N     3
                      28225    F                      TENOLYSIS, EXTENSOR; SINGLE                            N     3
                      28226    2                      TENOLYSIS, EXTENSOR; MULTIPLE, EACH                    N     3
                      28226    7                      TENOLYSIS, EXTENSOR; MULTIPLE, EACH                    N     3
                      28226    F                      TENOLYSIS, EXTENSOR; MULTIPLE, EACH                    N     3
                      28230    2                      TENOTOMY, OPEN, FLEXOR; FOOT, SINGLE OR MULTIPLE       N     3
                      28230    7                      TENOTOMY, OPEN, FLEXOR; FOOT, SINGLE OR MULTIPLE       N     3
                      28230    8                      TENOTOMY, OPEN, FLEXOR; FOOT, SINGLE OR MULTIPLE       N     3
                      28232    2                      TENOTOMY, OPEN, FLEXOR; TOE, SINGLE                    N     3
                      28232    7                      TENOTOMY, OPEN, FLEXOR; TOE, SINGLE                    N     3
                      28234    2                      TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE                  N     3
                      28234    7                      TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE                  N     3
                      28234    F                      TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE                  N     3
                      28236    7                      TRANSFER OF TENDON, ANTERIOR TIBIAL INTO TARSAL BO     N     3
                      28238    2                      ADVANCEMENT OF POSTERIOR TIBIAL TENDON WITH EXCISI     N     3
                      28238    7                      ADVANCEMENT OF POSTERIOR TIBIAL TENDON WITH EXCISI     N     3
                      28238    F                      ADVANCEMENT OF POSTERIOR TIBIAL TENDON WITH EXCISI     N     3
                      28240    2                      TENOTOMY OR RELEASE, ABDUCTOR HALLUCIS MUSCLE          N     3
                      28240    7                      TENOTOMY OR RELEASE, ABDUCTOR HALLUCIS MUSCLE          N     3
                      28240    F                      TENOTOMY OR RELEASE, ABDUCTOR HALLUCIS MUSCLE          N     3
                      28250    2                      DIVISION OF PLANTAR FASCIA AND MUSCLE (''STEINDLER     N     3
                      28250    7                      DIVISION OF PLANTAR FASCIA AND MUSCLE (''STEINDLER     N     3




Updated: 09/22/2006                                                                                                     Page: 109 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                 PA IND PAC
                      28250    8                      DIVISION OF PLANTAR FASCIA AND MUSCLE (''STEINDLER      N     3
                      28250    F                      DIVISION OF PLANTAR FASCIA AND MUSCLE (''STEINDLER      N     3
                      28260    2                      CAPSULOTOMY, MIDFOOT; MEDIAL RELEASE ONLY               N     3
                      28260    7                      CAPSULOTOMY, MIDFOOT; MEDIAL RELEASE ONLY               N     3
                      28260    8                      CAPSULOTOMY, MIDFOOT; MEDIAL RELEASE ONLY               N     3
                      28260    F                      CAPSULOTOMY, MIDFOOT; MEDIAL RELEASE ONLY               N     3
                      28261    2                      CAPSULOTOMY, MIDFOOT; WITH TENDON LENGTHENING           N     3
                      28261    7                      CAPSULOTOMY, MIDFOOT; WITH TENDON LENGTHENING           N     3
                      28261    8                      CAPSULOTOMY, MIDFOOT; WITH TENDON LENGTHENING           N     3
                      28261    F                      CAPSULOTOMY, MIDFOOT; WITH TENDON LENGTHENING           N     3
                      28262    2                      CAPSULOTOMY MIDFOOT EXT                                 N     3
                      28262    7                      CAPSULOTOMY, MIDFOOT;EXTENSIVE,INCLUDING POSTERIOR      N     3
                      28262    8                      CAPSULOTOMY, MIDFOOT;EXTENSIVE,INCLUDING POSTERIOR      N     3
                      28262    F                      CAPSULOTOMY MIDFOOT EXT                                 N     3
                      28264    2                      CAPSULOTOMY, MIDTARSAL (HEYMAN TYPE PROCEDURE)          N     3
                      28264    7                      CAPSULOTOMY, MIDTARSAL (HEYMAN TYPE PROCEDURE)          N     3
                      28264    8                      CAPSULOTOMY, MIDTARSAL (HEYMAN TYPE PROCEDURE)          N     3
                      28264    F                      CAPSULOTOMY, MIDTARSAL (HEYMAN TYPE PROCEDURE)          N     3
                      28270    2                      CAPSULOTOMY FOR CONTRACTURE;METATARSOPHALANGEAL JO      N     3
                      28270    7                      CAPSULOTOMY FOR CONTRACTURE;METATARSOPHALANGEAL JO      N     3
                      28270    8                      CAPSULOTOMY FOR CONTRACTURE;METATARSOPHALANGEAL JO      N     3
                      28270    F                      CAPSULOTOMY FOR CONTRACTURE;METATARSOPHALANGEAL JO      N     3
                      28272    2                      CAPSULOTOMY FOR CONTRACTURE;INTERPHALANGEAL JOINT,      N     3
                      28272    7                      CAPSULOTOMY FOR CONTRACTURE;INTERPHALANGEAL JOINT,      N     3
                      28280    2                      WEBBING OPERATION (CREATE SYNDACTYLISM OF TOES) FO      N     3
                      28280    7                      WEBBING OPERATION (CREATE SYNDACTYLISM OF TOES) FO      N     3
                      28280    F                      WEBBING OPERATION (CREATE SYNDACTYLISM OF TOES) FO      N     3
                      28285    2                      HAMMERTOE OPERATION; ONE TOE                            N     3
                      28285    7                      HAMMERTOE OPERATION; ONE TOE                            N     3
                      28285    8                      HAMMER TOE REPAIR ONE TOE                               N     3
                      28285    F                      HAMMERTOE OPERATION ONE TOE                             N     3
                      28286    2                      HAMMERTOE OPERATION; FOR COCK-UP FIFTH TOE WITH PL      N     3
                      28286    7                      HAMMERTOE OPERATION; FOR COCK-UP FIFTH TOE WITH PL      N     3
                      28286    F                      HAMMERTOE OPERATION; FOR COCK-UP FIFTH TOE WITH PL      N     3
                      28288    2                      OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY,SI      N     3
                      28288    7                      OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY,SI      N     3
                      28288    F                      OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY,SI      N     3
                      28289    2                      HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY              N     3
                      28289    7                      HALLUX RIGIDUS CORRECTION W/CHEILECTOMY DEBRIDEMENT     N     3
                      28289    F                      HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY              N     3
                      28290    2                      HALLUX VALGUS (BUNION),CORRECTION W OR W/OUT SESAM      N     3
                      28290    7                      HALLUX VALGUS (BUNION),CORRECTION W OR W/OUT SESAM      N     3
                      28290    F                      HALLUX VALGUS (BUNION),CORRECTION W OR W/OUT SESAM      N     3
                      28292    2                      HALLUX VALGUS (BUNION),W OR W/OUT SESAMOIDECTOMY;S      N     3
                      28292    7                      HALLUX VALGUS (BUNION),W OR W/OUT SESAMOIDECTOMY;S      N     3
                      28292    8                      HALLUX VALGUS (BUNION),W OR W/OUT SESAMOIDECTOMY;S      N     3
                      28292    F                      HALLUX VALGUS (BUNION),W OR W/OUT SESAMOIDECTOMY;S      N     3




Updated: 09/22/2006                                                                                                      Page: 110 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      28293    2                      HALLUX VALGUS (BUNION);RESECTION OF JOINT WITH IMP     N     3
                      28293    7                      HALLUX VALGUS (BUNION);RESECTION OF JOINT WITH IMP     N     3
                      28293    8                      HALLUX VALGUS (BUNION);RESECTION OF JOINT WITH IMP     N     3
                      28293    F                      HALLUX VALGUS (BUNION);RESECTION OF JOINT WITH IMP     N     3
                      28294    2                      HALLUX VALGUS (BUNION); WITH TENDON TRANSPLANTS        N     3
                      28294    7                      HALLUX VALGUS (BUNION); WITH TENDON TRANSPLANTS        N     3
                      28294    F                      HALLUX VALGUS (BUNION); WITH TENDON TRANSPLANTS        N     3
                      28296    2                      HALLUX VALGUS (BUNION); WITH METATARSAL OSTEOTOMY;     N     3
                      28296    7                      HALLUX VALGUS (BUNION); WITH METATARSAL OSTECTOMY;     N     3
                      28296    8                      HALLUX VALGUS (BUNION); WITH METATARSAL OSTECTOMY;     N     3
                      28296    F                      HALLUX VALGUS (BUNION); WITH METATARSAL OSTEOTOMY;     N     3
                      28297    2                      HALLUX VALGUS (BUNION) CORRECTION, WITH OR WITHOUT     N     3
                      28297    7                      HALLUX VALGUS (BUNION) CORRECTION, WITH OR WITHOUT     N     3
                      28297    F                      HALLUX VALGUS (BUNION) CORRECTION, WITH OR WITHOUT     N     3
                      28298    2                      HALLUX VALGUS (BUNION) CORRECTION; BY PHALANX OSTE     N     3
                      28298    7                      HALLUX VALGUS (BUNION) CORRECTION; BY PHALANX OSTE     N     3
                      28298    8                      HALLUX VALGUS (BUNION) CORRECTION; BY PHALANX OSTE     N     3
                      28298    F                      HALLUX VALGUS (BUNION) CORRECTION; BY PHALANX OSTE     N     3
                      28299    2                      HALLUX VALGUS (BUNION) CORRECTION; BY OTHER METHOD     N     3
                      28299    7                      HALLUX VALGUS (BUNION) CORRECTION; BY OTHER METHOD     N     3
                      28299    F                      HALLUX VALGUS (BUNION) CORRECTION; BY OTHER METHOD     N     3
                      28300    2                      OSTEOTOMY; CALCANEUS, WITH OR WITHOUT INTERNAL FIX     N     3
                      28300    7                      OSTEOTOMY; CALCANEUS, WITH OR WITHOUT INTERNAL FIX     N     3
                      28300    8                      OSTEOTOMY; CALCANEUS, WITH OR WITHOUT INTERNAL FIX     N     3
                      28300    F                      OSTEOTOMY; CALCANEUS, WITH OR WITHOUT INTERNAL FIX     N     3
                      28302    2                      OSTEOTOMY; TALUS                                       N     3
                      28302    7                      OSTEOTOMY; TALUS                                       N     3
                      28302    F                      OSTEOTOMY; TALUS                                       N     3
                      28304    2                      OSTEOTOMY, MIDTARSAL BONES, OTHER THAN CALCANEUS O     N     3
                      28304    7                      OSTEOTOMY, MIDTARSAL BONES, OTHER THAN CALCANEUS O     N     3
                      28304    8                      OSTEOTOMY, MIDTARSAL BONES, OTHER THAN CALCANEUS O     N     3
                      28304    F                      OSTEOTOMY, MIDTARSAL BONES, OTHER THAN CALCANEUS O     N     3
                      28305    7                      OSTEOTOMY, MIDTARSAL BONES, OTHER THAN CALCANEUS O     N     3
                      28305    F                      OSTEOTOMY, MIDTARSAL BONES, OTHER THAN CALCANEUS O     N     3
                      28306    2                      OSTEOTOMY,METATARSAL,BASE OR SHAFT,SINGLE,FOR SHOR     N     3
                      28306    7                      OSTEOTOMY,METATARSAL,BASE OR SHAFT,SINGLE,FOR SHOR     N     3
                      28306    8                      OSTEOTOMY,METATARSAL,BASE OR SHAFT,SINGLE,FOR SHOR     N     3
                      28306    F                      OSTEOTOMY,METATARSAL,BASE OR SHAFT,SINGLE,FOR SHOR     N     3
                      28307    7                      OSTEOTOMY, METATARSAL, BASE OR SHAFT, SINGLE, WITH     N     3
                      28307    F                      OSTEOTOMY, METATARSAL, BASE OR SHAFT, SINGLE, WITH     N     3
                      28308    2                      OSTEOTOMY,METATARSAL,BASE OR SHAFT,SINGLE,FOR SHOR     N     3
                      28308    7                      OSTEOTOMY,METATARSAL,BASE OR SHAFT,SINGLE,FOR SHOR     N     3
                      28308    8                      OSTEOTOMY,METATARSAL,BASE OR SHAFT,SINGLE,FOR SHOR     N     3
                      28308    F                      OSTEOTOMY,METATARSAL,BASE OR SHAFT,SINGLE,FOR SHOR     N     3
                      28309    2                      OSTEOTOMY, METATARSALS, MULTIPLE, FOR CAVUS FOOT       N     3
                      28309    7                      OSTEOTOMY, METATARSALS, MULTIPLE, FOR CAVUS FOOT       N     3
                      28309    F                      OSTEOTOMY, METATARSALS, MULTIPLE, FOR CAVUS FOOT       N     3




Updated: 09/22/2006                                                                                                     Page: 111 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      28310    2                      OSTEOTOMY FOR SHORTENING, ANGULAR OR ROTATIONAL CO                    N     3
                      28310    7                      OSTEOTOMY FOR SHORTENING, ANGULAR OR ROTATIONAL CO                    N     3
                      28310    F                      OSTEOTOMY FOR SHORTENING, ANGULAR OR ROTATIONAL CO                    N     3
                      28312    2                      OSTEOTOMY FOR SHORTENING, ANGULAR OR ROTATIONAL CO                    N     3
                      28312    7                      OSTEOTOMY FOR SHORTENING, ANGULAR OR ROTATIONAL CO                    N     3
                      28312    F                      OSTEOTOMY FOR SHORTENING, ANGULAR OR ROTATIONAL CO                    N     3
                      28313    7                      RECONSTRUCTION, ANGULAR DEFORMITY OF TOE (OVERLAPP                    N     3
                      28313    F                      RECONSTRUCTION, ANGULAR DEFORMITY OF TOE (OVERLAPP                    N     3
                      28315    2                      SESAMOIDECTOMY FIRST TOE (SEPARATE PROCEDURE)                         N     3
                      28315    7                      SESAMOIDECTOMY FIRST TOE (SEPARATE PROCEDURE)                         N     3
                      28315    8                      SESAMIODECTOMY FIRST TOE (SEPARATE PROCEDURE)                         N     3
                      28315    F                      SESAMOIDECTOMY FIRST TOE (SEPARATE PROCEDURE)                         N     3
                      28320    2                      REPAIR OF NONUNION OR MALUNION; TARSAL BONES                          N     3
                      28320    7                      REPAIR OF NONUNION OR MALUNION; TARSAL BONES                          N     3
                      28320    8                      REPAIR OF NONUNION OR MALUNION; TARSAL BONES                          N     3
                      28320    F                      REPAIR OF NONUNION OR MALUNION; TARSAL BONES                          N     3
                      28322    2                      REPAIR OF NONUNION OR MALUNION; METATARSAL, WITH O                    N     3
                      28322    7                      REPAIR OF NONUNION OR MALUNION; METATARSAL, WITH O                    N     3
                      28322    8                      REPAIR OF NONUNION OR MALUNION; METATARSAL, WITH O                    N     3
                      28322    F                      REPAIR OF NONUNION OR MALUNION; METATARSAL, WITH O                    N     3
                      28340    7                      RECONSTRUCTION, TOE, MACRODACTYLY                                     N     3
                      28340    F                      RECONSTRUCTION, TOE, MACRODACTYLY                                     N     3
                      28341    7                      RECONSTRUCTION, TOE, MACRODACTYLY                                     N     3
                      28341    F                      RECONSTRUCTION, TOE, MACRODACTYLY                                     N     3
                      28344    2                      RECONSTRUCTION, TOE(S)                                                N     3
                      28344    7                      RECONSTRUCTION, TOE(S)                                                N     3
                      28344    8                      RECONSTRUCTION, TOE(S)                                                N     3
                      28344    F                      RECONSTRUCTION, TOE(S)                                                N     3
                      28345    2                      RECONSTR TOE;SYNDACTYLY,W OR W/O SKIN GRAFT EA WEB                    N     3
                      28345    7                      RECONSTR TOE;SYNDACTYLY,W OR W/O SKIN GRAFT EA WEB                    N     3
                      28345    8                      RECONSTR TOE;SYNDACTYLY,W OR W/O SKIN GRAFT EA WEB                    N     3
                      28345    F                      RECONSTR TOE;SYNDACTYLY,W OR W/O SKIN GRAFT EA WEB                    N     3
                      28360    7                      RECONSTRUCTION, CLEFT FOOT                                            N     3
                      28400    2                      TREATMENT OF CLOSED CALCANEAL FRACTURE; WITHOUT MA                    N     3
                      28400    7                      TREATMENT OF CLOSED CALCANEAL FRACTURE; WITHOUT MA                    N     3
                      28400    F                      TREATMENT OF CLOSED CALCANEAL FRACTURE; WITHOUT MA                    N     3
                      28405    2                      TREATMENT OF CLOSED CALCANEAL FRACTURE;WITH MANIPU                    N     3
                      28405    7                      TREATMENT OF CLOSED CALCANEAL FRACTURE;WITH MANIPU                    N     3
                      28405    F                      TREATMENT OF CLOSED CALCANEAL FRACTURE;WITH MANIPU                    N     3
                      28406    2                      TREATMENT OF CLOSED CALCANEAL FRACTURE;WITH MANIPU                    N     3
                      28406    7                      ANESTHESIA,TREATMENT OF CLOSED CALCANEAL FRACTURE;WITH MANIPULATI     N     3
                      28406    F                      TREATMENT OF CLOSED CALCANEAL FRACTURE;WITH MANIPU                    N     3
                      28415    2                      OPEN TREATMENT OF CLOSED OR OPEN CALCANEAL FRACTUR                    N     3
                      28415    7                      OPEN TREATMENT OF CLOSED OR OPEN CALCANEAL FRACTUR                    N     3
                      28415    8                      OPEN TREATMENT OF CLOSED OR OPEN CALCANEAL FRACTUR                    N     3
                      28415    F                      OPEN TREATMENT OF CLOSED OR OPEN CALCANEAL FRACTUR                    N     3
                      28420    2                      OPEN TREATMENT OF CLOSED OR OPEN CALCANEAL FRACTUR                    N     3




Updated: 09/22/2006                                                                                                                    Page: 112 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      28420    7                      OPEN TREATMENT OF CLOSED OR OPEN CALCANEAL FRACTUR     N     3
                      28420    8                      OPEN TREATMENT OF CLOSED OR OPEN CALCANEAL FRACTUR     N     3
                      28420    F                      OPEN TREATMENT OF CLOSED OR OPEN CALCANEAL FRACTUR     N     3
                      28430    2                      TREATMENT OF CLOSED TALUS FRACTURE; WITHOUT MANIPU     N     3
                      28430    7                      TREATMENT OF CLOSED TALUS FRACTURE; WITHOUT MANIPU     N     3
                      28435    2                      TREATMENT OF CLOSED TALUS FRACTURE; WITH MANIPULAT     N     3
                      28435    7                      TREATMENT OF CLOSED TALUS FRACTURE; WITH MANIPULAT     N     3
                      28435    F                      TREATMENT OF CLOSED TALUS FRACTURE; WITH MANIPULAT     N     3
                      28436    7                      TREATMENT OF CLOSED TALUS FRACTURE                     N     3
                      28436    F                      TREATMENT OF CLOSED TALUS FRACTURE                     N     3
                      28445    2                      OPEN TREATMENT OF CLOSED OR OPEN TALUS FRACTURE, W     N     3
                      28445    7                      OPEN TREATMENT OF CLOSED OR OPEN TALUS FRACTURE, W     N     3
                      28445    8                      OPEN TREATMENT OF CLOSED OR OPEN TALUS FRACTURE, W     N     3
                      28445    F                      OPEN TREATMENT OF CLOSED OR OPEN TALUS FRACTURE, W     N     3
                      28450    2                      TREATMENT OF CLOSED TARSAL BONE FRACTURE (EXCEPT T     N     3
                      28450    7                      TREATMENT OF CLOSED TARSAL BONE FRACTURE (EXCEPT T     N     3
                      28455    2                      TREATMENT OF CLOSED TARSAL BONE FRACTURE (EXCEPT T     N     3
                      28455    7                      TREATMENT OF CLOSED TARSAL BONE FRACTURE (EXCEPT T     N     3
                      28456    7                      TREATMENT OF CLOSED TARSAL BONE FRACTURE (EXCEPT       N     3
                      28456    F                      TREATMENT OF CLOSED TARSAL BONE FRACTURE (EXCEPT       N     3
                      28465    2                      OPEN TREAT OF CLO OR OPEN TARSAL BONE FRAC(EX TALU     N     3
                      28465    7                      OPEN TREAT OF CLO OR OPEN TARSAL BONE FRAC(EX TALU     N     3
                      28465    8                      OPEN TREAT CLOS/OPEN TARSBONE FRAC INT/EXT SKEL FI     N     3
                      28465    F                      OPEN TREAT OF CLO OR OPEN TARSAL BONE FRAC(EX TALU     N     3
                      28470    2                      TREATMENT OF CLOSED METATARSAL FRACTURE; WITHOUT M     N     3
                      28470    7                      TREATMENT OF CLOSED METATARSAL FRACTURE; WITHOUT M     N     3
                      28475    2                      TREATMENT OF CLOSED METATARSAL FRACTURE; WITH MANI     N     3
                      28475    7                      TREATMENT OF CLOSED METATARSAL FRACTURE; WITH MANI     N     3
                      28476    2                      TREATMENT OF CLOSED METATARSAL FRACTURE                N     3
                      28476    7                      TREATMENT OF CLOSED METATARSAL FRACTURE                N     3
                      28476    8                      TREATMENT OF CLOSED METATARSAL FRACTURE                N     3
                      28476    F                      TREATMENT OF CLOSED METATARSAL FRACTURE                N     3
                      28485    2                      OPEN TREAT OF CLO OR OPEN METATARSAL FRAC,W OR W/O     N     3
                      28485    7                      OPEN TREAT OF CLO OR OPEN METATARSAL FRAC,W OR W/O     N     3
                      28485    F                      OPEN TREAT OF CLO OR OPEN METATARSAL FRAC,W OR W/O     N     3
                      28490    2                      TREATMENT OF CLOSED FRACTURE GREAT TOE, PHALANX OR     N     3
                      28490    7                      TREATMENT OF CLOSED FRACTURE GREAT TOE, PHALANX OR     N     3
                      28495    2                      TREATMENT OF CLOSED FRACTURE GREAT TOE, PHALANX OR     N     3
                      28495    7                      TREATMENT OF CLOSED FRACTURE GREAT TOE, PHALANX OR     N     3
                      28496    2                      TREATMENT OF CLOSED FRACTURE GREAT TOE, PHALANX        N     3
                      28496    7                      TREATMENT OF CLOSED FRACTURE GREAT TOE, PHALANX        N     3
                      28496    F                      TREATMENT OF CLOSED FRACTURE GREAT TOE, PHALANX        N     3
                      28505    2                      OPEN TREAT OF CLO OR OPEN FRAC GREAT TOE,PHALANX,P     N     3
                      28505    7                      OPEN TREAT OF CLO OR OPEN FRAC GREAT TOE,PHALANX,P     N     3
                      28505    F                      OPEN TREAT OF CLO OR OPEN FRAC GREAT TOE,PHALANX,P     N     3
                      28510    2                      TREAT OF CLOSED FRAC,PHALANX OR PHALANGES,OTHER TH     N     3
                      28510    7                      TREAT OF CLOSED FRAC,PHALANX OR PHALANGES,OTHER TH     N     3




Updated: 09/22/2006                                                                                                     Page: 113 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      28515    2                      TREAT OF CLOSED FRAC,PHALANX OR PHALANGES,OTHER TH     N     3
                      28515    7                      TREAT OF CLOSED FRAC,PHALANX OR PHALANGES,OTHER TH     N     3
                      28525    2                      OPEN TREAT OF CLO OR OPEN FRAC;WITH OR WITHOUT INT     N     3
                      28525    7                      OPEN TREAT OF CLO OR OPEN FRAC;WITH OR WITHOUT INT     N     3
                      28525    F                      OPEN TREAT OF CLO OR OPEN FRAC;WITH OR WITHOUT INT     N     3
                      28530    7                      TREATMENT OF CLOSED SESAMOID FRACTURE                  N     3
                      28531    2                      OPEN TREATMENT OF SESAMOID FRACTURE, WITH OR WITHO     N     3
                      28531    7                      OPEN TRTMT OF SESAMOID FX W/OR WO ENTERNAL FIXATIO     N     3
                      28531    F                      OPEN TREATMENT OF SESAMOID FRACTURE, WITH OR WITHO     N     3
                      28540    2                      TREATMENT OF CLOSED TARSAL BONE DISLOCATION; WITHO     N     3
                      28545    2                      TREATMENT OF CLOSED TARSAL BONE DISLOCATION; REQUI     N     3
                      28545    7                      TREATMENT OF CLOSED TARSAL BONE DISLOCATION; REQUI     N     3
                      28545    F                      TREATMENT OF CLOSED TARSAL BONE DISLOCATION; REQUI     N     3
                      28546    7                      TREATMENT OF CLOSED TARSAL BONE DISLOCATION, WITH      N     3
                      28546    F                      TREATMENT OF CLOSED TARSAL BONE DISLOCATION, WITH      N     3
                      28555    2                      OPEN TREAT OF CLO OR OPEN TARSAL BONE DISLOCATION,     N     3
                      28555    7                      OPEN TREAT OF CLO OR OPEN TARSAL BONE DISLOCATION,     N     3
                      28555    8                      OPEN TREAT OF CLO OR OPEN TARSAL BONE DISLOCATION,     N     3
                      28555    F                      OPEN TREAT OF CLO OR OPEN TARSAL BONE DISLOCATION,     N     3
                      28570    2                      TREATMENT OF CLOSED TALOTARSAL JOINT DISLOCATION;      N     3
                      28575    2                      TREATMENT OF CLOSED TALOTARSAL JOINT DISLOCATION;      N     3
                      28575    7                      TREATMENT OF CLOSED TALOTARSAL JOINT DISLOCATION;      N     3
                      28575    F                      TREATMENT OF CLOSED TALOTARSAL JOINT DISLOCATION;      N     3
                      28576    2                      PERCUTANEOUS SKELETAL FIXATION OF TALOTARSAL JOINT     N     3
                      28576    7                      PERCUTANEOUS SLELETAL FIXATION OF TALOTARSAL JNT       N     3
                      28576    F                      PERCUTANEOUS SKELETAL FIXATION OF TALOTARSAL JOINT     N     3
                      28585    2                      OPEN TREAT OF CLO OR OPEN TALOTARSAL JOINT DISLO,W     N     3
                      28585    7                      OPEN TREAT OF CLO OR OPEN TALOTARSAL JOINT DISLO,W     N     3
                      28585    8                      OPEN TREAT OF CLO OR OPEN TALOTARSAL JOINT DISLO,W     N     3
                      28585    F                      OPEN TREAT OF CLO OR OPEN TALOTARSAL JOINT DISLO,W     N     3
                      28600    2                      TREATMENT OF CLOSED TARSOMETATARSAL JOINT DISLOCAT     N     3
                      28605    2                      TREATMENT OF CLOSED TARSOMETATARSAL JOINT DISLOCAT     N     3
                      28605    7                      TREATMENT OF CLOSED TARSOMETATARSAL JOINT DISLOCAT     N     3
                      28605    F                      TREATMENT OF CLOSED TARSOMETATARSAL JOINT DISLOCAT     N     3
                      28606    7                      TREAT OF CLOSED TARSOMETATARSAL JOINT DISLOCATION,     N     3
                      28606    F                      TREAT OF CLOSED TARSOMETATARSAL JOINT DISLOCATION,     N     3
                      28615    2                      OPEN TREAT OF CLO OR OPEN TARSOMETATARSAL DIS,W OR     N     3
                      28615    7                      OPEN TREAT OF CLO OR OPEN TARSOMETATARSAL DIS,W OR     N     3
                      28615    8                      OPEN TREAT OF CLO OR OPEN TARSOMETATARSAL DIS,W OR     N     3
                      28615    F                      OPEN TREAT OF CLO OR OPEN TARSOMETATARSAL DIS,W OR     N     3
                      28630    2                      TREAT OF CLOSED METATARSOPHALANGEAL JOINT DISLOCAT     N     3
                      28635    2                      TREAT OF CLOSED METATARSOPHALANGEAL JOINT DISLOCAT     N     3
                      28635    7                      TREAT OF CLOSED METATARSOPHALANGEAL JOINT DISLOCAT     N     3
                      28635    F                      TREAT OF CLOSED METATARSOPHALANGEAL JOINT DISLOCAT     N     3
                      28636    2                      PERCUTANEOUS SKELETAL FIXATION OF METATARSOPHALANG     N     3
                      28636    7                      PERCUTANEOUS SKELETAL FIXATION METATARSOPHALANGEAL     N     3
                      28636    F                      PERCUTANEOUS SKELETAL FIXATION OF METATARSOPHALANG     N     3




Updated: 09/22/2006                                                                                                     Page: 114 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      28645    2                      OPEN TREATMENT OF CLOSED OR OPEN METATARSOPHALANGE     N     3
                      28645    7                      OPEN TREATMENT OF CLOSED OR OPEN METATARSOPHALANGE     N     3
                      28645    F                      OPEN TREATMENT OF CLOSED OR OPEN METATARSOPHALANGE     N     3
                      28660    2                      TREATMENT OF CLOSED INTERPHALANGEAL JOINT DISLOCAT     N     3
                      28665    2                      TREATMENT OF CLOSED INTERPHALANGEAL JOINT DISLOCAT     N     3
                      28665    7                      TREATMENT OF CLOSED INTERPHALANGEAL JOINT DISLOCAT     N     3
                      28665    F                      TREATMENT OF CLOSED INTERPHALANGEAL JOINT DISLOCAT     N     3
                      28666    2                      PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL      N     3
                      28666    7                      PERCUTANEOUS SKELETAL FIXATION INTERPHALANGEAL JOI     N     3
                      28666    F                      PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL      N     3
                      28675    2                      OPERN RED INTER FRA                                    N     3
                      28675    7                      OPEN TREATMENT OF CLOSED OR OPEN INTERPHALANGEAL J     N     3
                      28675    F                      OPERN RED INTER FRA                                    N     3
                      28705    2                      PANTALAR ARTHRODESIS                                   N     3
                      28705    7                      PANTALAR ARTHRODESIS                                   N     3
                      28705    8                      PANTALAR ARTHRODESIS                                   N     3
                      28705    F                      PANTALAR ARTHRODESIS                                   N     3
                      28715    2                      TRIPLE ARTHRODESIS                                     N     3
                      28715    7                      TRIPLE ARTHRODESIS                                     N     3
                      28715    8                      TRIPLE ARTHRODESIS                                     N     3
                      28715    F                      TRIPLE ARTHRODESIS                                     N     3
                      28725    2                      SUBTALAR ARTHRODESIS (INCLUDES GRICE TYPE PROCEDUR     N     3
                      28725    7                      SUBTALAR ARTHRODESIS (INCLUDES GRICE TYPE PROCEDUR     N     3
                      28725    8                      SUBTALAR ARTHRODESIS (INCLUDES GRICE TYPE PROCEDUR     N     3
                      28725    F                      SUBTALAR ARTHRODESIS (INCLUDES GRICE TYPE PROCEDUR     N     3
                      28730    2                      ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPL     N     3
                      28730    7                      ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPL     N     3
                      28730    8                      ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPL     N     3
                      28730    F                      ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPL     N     3
                      28735    2                      ARTHRODESIS,MIDTARSAL OR TARSOMETATARSAL,MULT OR T     N     3
                      28735    7                      ARTHRODESIS,MIDTARSAL OR TARSOMETATARSAL,MULT OR T     N     3
                      28735    8                      ARTHRODESIS,MIDTARSAL OR TARSOMETATARSAL,MULT OR T     N     3
                      28735    F                      ARTHRODESIS,MIDTARSAL OR TARSOMETATARSAL,MULT OR T     N     3
                      28737    2                      ARTHRODESIS,MIDTARSAL NAVICULAR-CUNEIFORM,WITH TEN     N     3
                      28737    7                      ARTHRODESIS,MIDTARSAL NAVICULAR-CUNEIFORM,WITH TEN     N     3
                      28737    F                      ARTHRODESIS,MIDTARSAL NAVICULAR-CUNEIFORM,WITH TEN     N     3
                      28740    2                      ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, SINGLE      N     3
                      28740    7                      ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, SINGLE      N     3
                      28740    F                      ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, SINGLE      N     3
                      28750    2                      ARTHRODESIS, GREAT TOE; METATARSOPHALANGEAL JOINT      N     3
                      28750    7                      ARTHRODESIS, GREAT TOE; METATARSOPHALANGEAL JOINT      N     3
                      28750    F                      ARTHRODESIS, GREAT TOE; METATARSOPHALANGEAL JOINT      N     3
                      28755    2                      ARTHRODESIS, GREAT TOE; INTERPHALANGEAL JOINT          N     3
                      28755    7                      ARTHRODESIS, GREAT TOE; INTERPHALANGEAL JOINT          N     3
                      28755    F                      ARTHRODESIS, GREAT TOE; INTERPHALANGEAL JOINT          N     3
                      28760    2                      ARTHRODESIS,GREAT TOE,INTERPHALANGEAL JOINT,WITH E     N     3
                      28760    7                      ARTHRODESIS,GREAT TOE,INTERPHALANGEAL JOINT,WITH E     N     3




Updated: 09/22/2006                                                                                                     Page: 115 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      28760    F                      ARTHRODESIS,GREAT TOE,INTERPHALANGEAL JOINT,WITH E     N     3
                      28800    2                      AMPUTATION, FOOT; MIDTARSAL                            N     3
                      28800    7                      AMPUTATION, FOOT; MIDTARSAL                            N     3
                      28800    8                      AMPUTATION, FOOT; MIDTARSAL                            N     3
                      28805    2                      AMPUTATION, FOOT; TRANSMETATARSAL                      N     3
                      28805    7                      AMPUTATION, FOOT; TRANSMETATARSAL                      N     3
                      28805    8                      AMPUTATION, FOOT; TRANSMETATARSAL                      N     3
                      28810    2                      AMPUTATION, METATARSAL, WITH TOE, SINGLE               N     3
                      28810    7                      AMPUTATION, METATARSAL, WITH TOE, SINGLE               N     3
                      28810    8                      AMPUTATION, METATARSAL, WITH TOE, SINGLE               N     3
                      28810    F                      AMPUTATION, METATARSAL, WITH TOE, SINGLE               N     3
                      28820    2                      AMPUTATION, TOE; METATARSOPHALANGEAL JOINT             N     3
                      28820    7                      AMPUTATION, TOE; METATARSOPHALANGEAL JOINT             N     3
                      28820    F                      AMPUTATION, TOE; METATARSOPHALANGEAL JOINT             N     3
                      28825    2                      AMPUTATION, TOE; INTERPHALANGEAL JOINT                 N     3
                      28825    7                      AMPUTATION, TOE; INTERPHALANGEAL JOINT                 N     3
                      28825    F                      AMPUTATION, TOE; INTERPHALANGEAL JOINT                 N     3
                      28899    7                      UNLISTED PROCEDURE, FOOT OR TOES                       N     3
                      29000    2                      APPLICATION OF HALO TYPE BODY CAST (SEE 20661-2066     N     3
                      29000    7                      APPLIC OF HALO TYPE BODY CAST                          N     3
                      29010    2                      APPLICATION OF RISSER JACKET, LOCALIZER, BODY; ONL     N     3
                      29010    7                      APPLIC RISSER JACKET LOCALIZER BODY ONLY               N     3
                      29015    2                      APPLICATION OF RISSER JACKET, LOCALIZER, BODY; INC     N     3
                      29015    7                      APPLIC RISSER JACK LOCAL BODY INCLUDING HEAD           N     3
                      29020    2                      APPLICATION OF TURNBUCKLE JACKET, BODY; ONLY           N     3
                      29020    7                      APPLIC TURNBUCKLE JACKET BODY ONLY                     N     3
                      29025    2                      APPLICATION OF TURNBUCKLE JACKET, BODY; INCLUDING      N     3
                      29025    7                      APPLIC TURNBUCKLE JACKET BODY INCLUD HEAD              N     3
                      29035    2                      APPLICATION OF BODY CAST, SHOULDER TO HIPS;            N     3
                      29035    7                      APPLIC BODY CAST SHOULDER TO HIPS                      N     3
                      29040    2                      APPLICATION OF BODY CAST, SHOULDER TO HIPS; INCLUD     N     3
                      29040    7                      APPLIC BODY CAST SHOULDER TO HIP INC HEAD MINERVA      N     3
                      29044    2                      APPLICATION OF BODY CAST, SHOULDER TO HIPS; INCLUD     N     3
                      29044    7                      APPLIC BODY CAST SHOULDER TO HIP WITH ONE THIGH        N     3
                      29046    2                      APPLICATION OF BODY CAST, SHOULDER TO HIPS; INCLUD     N     3
                      29046    7                      APPLIC BODY CAST SHOULDER TO HIP WITH BOTH THIGHS      N     3
                      29049    2                      APPLICATION; PLASTER FIGURE OF EIGHT                   N     3
                      29055    2                      APPLICATION; SHOULDER SPICA                            N     3
                      29055    7                      APPLIC SHOULDER SPICA                                  N     3
                      29065    2                      APPLICATION; SHOULDER TO HAND CAST                     N     3
                      29075    2                      APPLICATION; ELBOW TO FINGER - CASTING                 N     3
                      29085    2                      APPLICATION; HAND AND LOWER FOREARM                    N     3
                      29086    1                      APPLICATION, CAST, FINGER (EG CONTRACTURE)             N     3
                      29086    2                      APPLICATION, CAST, FINGER (EG CONTRACTURE)             N     3
                      29105    2                      APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND)      N     3
                      29125    2                      APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND);     N     3
                      29126    2                      APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND);     N     3




Updated: 09/22/2006                                                                                                     Page: 116 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                          PA IND PAC
                      29130    2                      APPLICATION OF FINGER SPLINT; STATIC                             N     3
                      29131    2                             FINGER SPLINT                                             N     3
                      29200    2                      STRAPPING; THORAX                                                N     3
                      29220    2                      STRAPPING; LOW BACK                                              N     3
                      29240    2                      STRAPPING; SHOULDER                                              N     3
                      29260    2                      STRAPPING; ELBOW OR WRIST                                        N     3
                      29280    2                      STRAPPING; HAND OR FINGER                                        N     3
                      29305    2                      APPLICATION OF HIP SPICA CAST; UNILATERAL                        N     3
                      29305    7                      APPLICATION OF HIP SPICA CAST; UNILATERAL                        N     3
                      29325    2                      APPLICATION OF HIP SPICA CAST; BILATERAL, OR ONE A               N     3
                      29325    7                      APPLIC HIP SPICA CAST BILAT/ONE-ONE HALF SPICA                   N     3
                      29345    2                      APPLICATION OF LONG LEG CAST (THIGH TO TOES)                     N     3
                      29345    7                      APPLICATION OF LONG LEG CAST (THIGH TO TOES)                     N     3
                      29355    2                      APPLICATION OF LONG LEG CAST (THIGH TO TOES); WALK               N     3
                      29356    8                      FLEXOR TENDON REPAIR OR ADUANCE, SINGL, IN NO MAN'               N     3
                      29358    2                      APPLICATION OF LONG LEG CAST BRACE                               N     3
                      29365    2                      APPLICATION OF CYLINDER CAST (THIGH TO ANKLE)                    N     3
                      29405    2                      APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES)               N     3
                      29425    2                      APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES)               N     3
                      29435    2                      APPLICATION OF PATELLAR TENDON BEARING (PTB) CAST                N     3
                      29440    2                      ADDING WALKER TO PREVIOUSLY APPLIED CAST                         N     3
                      29445    2                      APPLICATION OF RIGID TOTAL CONTACT LEG CAST                      N     3
                      29450    2                      APPL OF CLUBFOOT CAS W/MOLDING OR MANIPULATING                   N     3
                      29450    7                      APPLIC CLUBFOOT CAST MOLD/MANIP LONG/SHORT LEG UNI               N     3
                      29505    2                      APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR                N     3
                      29515    2                      APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT)                   N     3
                      29520    2                      STRAPPING; HIP                                                   N     3
                      29530    2                      STRAPPING; KNEE                                                  N     3
                      29540    2                      STRAPPING; ANKLE                                                 N     3
                      29550    2                      STRAPPING; TOES                                                  N     3
                      29580    2                      STRAPPING; UNNA BOOT                                             N     3
                      29590    2                      DENIS-BROWNE SPLINT STRAPPING                                    N     3
                      29700    2                      REMOVAL OR BIVALVING; GAUNTLET, BOOT OR BODY CAST                N     3
                      29705    2                      REMOVAL OR BIVALVING; FULL ARM OR FULL LEG CAST                  N     3
                      29705    7                      REMOVAL OR BIVALVING FULL ARM OR FULL LEG                        N     3
                      29710    2                      REMOVAL OR BIVALVING; SHOULDER OR HIP SPICA, MINER               N     3
                      29710    7                      REMOVAL OR BIVALVING; SHOULDER OR HIP SPICA, MINER               N     3
                      29715    2                      REMOVAL OR BIVALVING; TURNBUCKLE JACKET                          N     3
                      29720    2                      REPAIR OF SPICA, BODY CAST OR JACKET                             N     3
                      29730    2                      WINDOWING OF CAST                                                N     3
                      29740    2                      WEDGING OF CAST (EXCEPT CLUBFOOT CASTS)                          N     3
                      29799    7                      UNLISTED PROCEDURE, CASTING OR STRAPPING                         N     3
                      29800    7                      ARTHROSCOPY                                                      N     3
                      29800    F                      ARTHROSCOPY                                                      N     3
                      29804    7                      ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, SURGICAL                   N     3
                      29804    F                      ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, SURGICAL                   N     3
                      29805    2                      ARTHROSCOPY CHOULDER, DIAGNOSTIC WITH OR W/O SYNOVIAL BIOPSY     N     3




Updated: 09/22/2006                                                                                                               Page: 117 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      29805    F                      ARTHROSCOPY CHOULDER, DIAGNOSTIC WITH OR W/O SYNOVIAL BIOPSY          N     3
                      29806    2                      ARTHROXCOPY, SHOULDER, SURGICAL CAPSULORRHAPHY                        N     3
                      29806    F                      ARTHROXCOPY, SHOULDER, SURGICAL CAPSULORRHAPHY                        N     3
                      29807    2                      ARTHROSCOPY, SHOULDER, SURGICAL REPAIR OF SLAP LESION                 N     3
                      29807    F                      ARTHROSCOPY, SHOULDER, SURGICAL REPAIR OF SLAP LESION                 N     3
                      29815    7                      ARTHROSCOPY SHOULD DIAGNOSTIC W/WO BIOP SEPR PROCD                    N     3
                      29819    2                      ARTHROSCOPY, SHOULDER, SURGICAL                                       N     3
                      29819    7                      ARTHROSCOPY, SHOULDER, SURGICAL                                       N     3
                      29819    F                      ARTHROSCOPY, SHOULDER, SURGICAL                                       N     3
                      29820    2                      ARTHROSCOPY, SHOULDER, SURGICAL                                       N     3
                      29820    7                      ARTHROSCOPY, SHOULDER, SURGICAL                                       N     3
                      29820    F                      ARTHROSCOPY, SHOULDER, SURGICAL                                       N     3
                      29821    7                      ARTHROSCOPY, SHOULDER, SURGICAL                                       N     3
                      29821    F                      ARTHROSCOPY, SHOULDER, SURGICAL                                       N     3
                      29822    2                      ARTHROSCOPY SHLDR SURG W LMTD DEBRIDEMNT                              N     3
                      29822    7                      ANESTHESIA FOR ARTHROSCOPY SHOULDER SURGERY WITH LIMITED DEBRIDME     N     3
                      29822    F                      ARTHROSCOPY SHLDR SURG W LMTD DEBRIDEMNT                              N     3
                      29823    2                      ARTHROSCOPY SHLDR SURGICAL W EXTENSIVE DEBRIDEMENT                    N     3
                      29823    7                      ANESTHESIA, ARTHROSCOPY SHOULDER SURGICAL W/EXTENSIVE DEBRIDMENT      N     3
                      29823    F                      ARTHROSCOPY SHLDR SURGICAL W EXTENSIVE DEBRIDEMENT                    N     3
                      29824    2                      ARTHOSCOPY, SHOULDER SURGICAL DISTAL CLAVICULECTOMY INC DISTAL        N     3
                      29824    F                      ARTHOSCOPY, SHOULDER SURGICAL DISTAL CLAVICULECTOMY INC DISTAL        N     3
                      29825    2                      ARTHROSCOPY, SHOULDER, SURGICAL                                       N     3
                      29825    7                      ARTHROSCOPY, SHOULDER, SURGICAL                                       N     3
                      29825    F                      ARTHROSCOPY, SHOULDER, SURGICAL                                       N     3
                      29826    2                      DCMPRSSN SBCRML SP W PRTL ACRMPLSTY W/WO CRCRML RL                    N     3
                      29826    7                      DCMPRSSN SBCRML SP W PRTL ACRMPLSTY W/WO CRCRML RL                    N     3
                      29826    8                      DCMPRSSN SBCRML SP W PRTL ACRMPLSTY W/WO CRCRML RL                    N     3
                      29826    F                      DCMPRSSN SBCRML SP W PRTL ACRMPLSTY W/WO CRCRML RL                    N     3
                      29827    2                      ARTHROSCOPY SHOULDER SURG W/ROTATOR CUFF REPAIR                       N     3
                      29827    4                      ARTHROSCOPY SHOULDER SURG W/ ROTATOR CUFF REPAIR                      N     3
                      29830    2                      ARTHROSCOPY ELBW DIAGNOSTIC W/WO BIOP INDPT PROCDR                    N     3
                      29830    7                      ARTHROSCOPY ELBW DIAGNOSTIC W/WO BIOP INDPT PROCDR                    N     3
                      29830    F                      ARTHROSCOPY ELBW DIAGNOSTIC W/WO BIOP INDPT PROCDR                    N     3
                      29834    2                      ARTHROSCOPY ELBOW SURG W RMVL LS BDY FOR BDY                          N     3
                      29834    7                      ANESTHESIA,ARTHROSCOPY ELBOW SURG. W/REMOV.LS BDY FOR BDY             N     3
                      29834    F                      ARTHROSCOPY ELBOW SURG W RMVL LS BDY FOR BDY                          N     3
                      29835    7                      ARTHROSCOPY, ELBOW, SURGICAL                                          N     3
                      29835    F                      ARTHROSCOPY, ELBOW, SURGICAL                                          N     3
                      29836    2                      ARTHROSCOPY, ELBOW, SURGICAL                                          N     3
                      29836    7                      ARTHROSCOPY, ELBOW, SURGICAL                                          N     3
                      29836    F                      ARTHROSCOPY, ELBOW, SURGICAL                                          N     3
                      29837    2                      ARTHROSCOPY-ELBOW/DEBRIDEMENT LIMITED                                 N     3
                      29837    7                      ARTHROSCOPY-ELBOW/DEBRIDEMENT LIMITED                                 N     3
                      29837    F                      ARTHROSCOPY-ELBOW/DEBRIDEMENT LIMITED                                 N     3
                      29838    7                      ARTHROSCOPY, ELBOW, SURGICAL                                          N     3
                      29838    F                      ARTHROSCOPY, ELBOW, SURGICAL                                          N     3




Updated: 09/22/2006                                                                                                                    Page: 118 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      29840    2                      ARTHROSCOPY, WRIST, DIAGNOSTIC, WITH OR WITHOUT SY                    N     3
                      29840    7                      ARTHROSCOPY, WRIST, DIAGNOSTIC, WITH OR WITHOUT SY                    N     3
                      29840    F                      ARTHROSCOPY, WRIST, DIAGNOSTIC, WITH OR WITHOUT SY                    N     3
                      29843    2                      ARTHROSCOPY, WRIST, SURGICAL                                          N     3
                      29843    7                      ARTHROSCOPY, WRIST, SURGICAL                                          N     3
                      29843    F                      ARTHROSCOPY, WRIST, SURGICAL                                          N     3
                      29844    2                      ARTHROSCOPY, WRIST, SURGICAL                                          N     3
                      29844    7                      ARTHROSCOPY, WRIST, SURGICAL                                          N     3
                      29844    F                      ARTHROSCOPY, WRIST, SURGICAL                                          N     3
                      29845    7                      ARTHROSCOPY, WRIST, SURGICAL                                          N     3
                      29845    F                      ARTHROSCOPY, WRIST, SURGICAL                                          N     3
                      29846    2                      ARTHRSCPY EXCSN TRNGLR FBRCRTLGE / JNT DBRDMNT                        N     3
                      29846    7                      ARTHRSCPY EXCSN TRNGLR FBRCRTLGE / JNT DBRDMNT                        N     3
                      29846    F                      ARTHRSCPY EXCSN TRNGLR FBRCRTLGE / JNT DBRDMNT                        N     3
                      29847    7                      ARTHROSCOPY, WRIST, SURGICAL                                          N     3
                      29847    F                      ARTHROSCOPY, WRIST, SURGICAL                                          N     3
                      29848    2                      ARTHROSCOPY, WRIST, SURGICAL;                                         N     3
                      29848    7                      ARTHROSCOPY, WRIST, SURGICAL;                                         N     3
                      29848    F                      ARTHROSCOPY, WRIST, SURGICAL;                                         N     3
                      29850    2                      ARTHROSCOPICALLY AIDED TREATMENT OF INTERCONDYLAR                     N     3
                      29850    7                      ARTHPOSCOPICALLY AIDED TRTMT OF INTERCONDYLAR SPIN                    N     3
                      29850    F                      ARTHROSCOPICALLY AIDED TREATMENT OF INTERCONDYLAR                     N     3
                      29851    2                      ARTHROSCOPICALLY AIDED TREATMENT OF INTERCONDYLAR                     N     3
                      29851    7                      ARTHROSCOPICALLY AIDED TRTMT OF INTER SPINE W/EXT                     N     3
                      29851    F                      ARTHROSCOPICALLY AIDED TREATMENT OF INTERCONDYLAR                     N     3
                      29855    2                      ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTUR                    N     3
                      29855    7                      ARTHROSCOPICALLY AIDED TRTMT OF TIBIAL FX PROXIMAL                    N     3
                      29855    F                      ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTUR                    N     3
                      29856    2                      ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTUR                    N     3
                      29856    7                      ARTHROSCOP AIDED TRTMT OF TIBIAL FX PROXIMAL BIOCO                    N     3
                      29856    F                      ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTUR                    N     3
                      29860    2                      ARTHROSCOPY,HIP,DIAGNOSTIC;W/WO SYNOVIAL BIOPSY(SEPARATE PROCEDUR     N     3
                      29860    7                      ARTHROSCOPY,HIP,DIAG.;W/WO SYNOVIAL BIOPSY (SEPARATE PROCEDURE)       N     3
                      29860    8                      ARTHROSCOPY,HIP,DIAG.;W/WO SYNOVIAL BIOPSY (SEPARATE PROCEDURE)       N     3
                      29860    F                      ARTHROSCOPY,HIP,DIAGNOSTIC;W/WO SYNOVIAL BIOPSY(SEPARATE PROCEDUR     N     3
                      29861    2                      ARTHROSCOPY,HIP,SURGICAL;WITH REMOVAL LOOSE OR FOREIGN BODY           N     3
                      29861    7                      ARTHROSCOPY,HIP,SURGICAL;W/REMOVAL LOOSE OR FOREIGN BODY              N     3
                      29861    8                      ARTHROSCOPY,HIP,SURGICAL;W/REMOVAL OF LOOSE/FOREIGN BODY              N     3
                      29861    F                      ARTHROSCOPY,HIP,SURGICAL;WITH REMOVAL LOOSE OR FOREIGN BODY           N     3
                      29862    2                      ARTHROSCOPY,HIP,SURGICAL;W/DEBRIDE/SHAVING ARTICULAR CARTILAGE        N     3
                      29862    8                      ARTHORSCOPY,HIP,SURGICAL;W/DEBRIDE/SHAVING ARTICULAR CARTILAGE        N     3
                      29862    F                      ARTHROSCOPY,HIP,SURGICAL;W/DEBRIDE/SHAVING ARTICULAR CARTILAGE        N     3
                      29863    2                      ARTHROSCOPY,HIP,SURGICAL;W/SYNOVECTOMY                                N     3
                      29863    7                      ARTHROSCOPY,HIP,SURGICAL;W/DEBRIDE/SHAVING,ARTICULAR CARTILAGE        N     3
                      29863    8                      ARTHROSCOPY,HIP,SURGICAL;W/SYNOVECTOMY                                N     3
                      29863    F                      ARTHROSCOPY,HIP,SURGICAL;W/SYNOVECTOMY                                N     3
                      29866    2                      ARTHROSCOPY KNEE SURGICAL OSTEOCHAONDRAL AUTOGRAFTS                   Y     3




Updated: 09/22/2006                                                                                                                    Page: 119 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                          PA IND PAC
                      29866    7                      ARTHROSCOPY KNEE SURGICAL OSTEOCHONDRAL AUTOGRA                  Y     3
                      29867    2                      ARTHROSCOPY KNEE SURGICAL OSTEOCHONDRAL ALLOGRAFT                Y     3
                      29867    7                      ARTHROSCOPY KNEE SURGICAL OSTEOCHONDRAL ALLOGRAFT                N     3
                      29868    2                      ARTHROSCOPY KNEE SURGICAL MENISCAL TRANSPLANTATION               N     3
                      29868    7                      ARTHROSCOPY,KNEE,SURGICAL,MENSICAL TRANSPL                       N     3
                      29870    2                      ARTHROSCOPY KNEE DIAGNOSTIC W/WO BIOP SEP PROCEDUR               N     3
                      29870    7                      ARTHROSCOPY KNEE DIAGNOSTIC W/WO BIOP SEP PROCEDUR               N     3
                      29870    F                      ARTHROSCOPY KNEE DIAGNOSTIC W/WO BIOP SEP PROCEDUR               N     3
                      29871    2                      ARTHROSCOPY KNEE SURG FOR INFCTN LVGE DRAINAGE                   N     3
                      29871    7                      ARTHROSCOPY KNEE SURG FOR INFCTN LVGE DRAINAGE                   N     3
                      29871    F                      ARTHROSCOPY KNEE SURG FOR INFCTN LVGE DRAINAGE                   N     3
                      29873    2                      ARTHOSCOPY KNEE SURG W/LATERAL RELEASE                           N     3
                      29873    4                      ARTHROSCOPY KNEE SURG W/ LATERAL RELEASE                         N     3
                      29874    2                      ARTHRSCPY KNE FOR REMUL LOOSE BDY OR F.B.                        N     3
                      29874    7                      ARTHRSCPY KNE FOR REMUL LOOSE BDY OR F.B.                        N     3
                      29874    8                      ARTHRSCPY KNE FOR REMUL LOOSE BOY OR FB                          N     3
                      29874    F                      ARTHRSCPY KNE FOR REMUL LOOSE BDY OR F.B.                        N     3
                      29875    2                      ARTHROTOMY KNEE SYNOVECTOMY LIMTD EG PLICA                       N     3
                      29875    7                      ARTHROSCOPY KNEE W SYNOVECTMY LMTD EG PLICA                      N     3
                      29875    F                      ARTHROTOMY KNEE SYNOVECTOMY LIMTD EG PLICA                       N     3
                      29876    2                      ARTHROSCOPY KNEE W SYNOVECTOMY MJR TWO OR MO CMPTS               N     3
                      29876    7                      ARTHROSCOPY KNEE W SYNOVECTOMY MJR TWO OR MO CMPTS               N     3
                      29876    F                      ARTHROSCOPY KNEE W SYNOVECTOMY MJR TWO OR MO CMPTS               N     3
                      29877    2                      ARTHROSCOPY DEBRIDEMENT 1 SHAVING CHONDROPLASTY KN               N     3
                      29877    7                      ARTHROSCOPY DEBRIDEMENT 1 SHAVING CHONDROPLASTY KN               N     3
                      29877    8                      ARTHROSCOPY DEBRIDEMENT 1 SHAVING CHONDROPLASTY KN               N     3
                      29877    F                      ARTHROSCOPY DEBRIDEMENT 1 SHAVING CHONDROPLASTY KN               N     3
                      29879    2                      ARTHRSCPY KNEE SURG ABRSN ARTRPLAST CHNDPLAST DRIL               N     3
                      29879    F                      ARTHRSCPY KNEE SURG ABRSN ARTRPLAST CHNDPLAST DRIL               N     3
                      29880    2                      ABRASION ARTHROPLASTY/WITH MANISCETOMY                           N     3
                      29880    7                      ABRASION ARTHROPLASTY/WITH MANISCETOMY                           N     3
                      29880    F                      ABRASION ARTHROPLASTY/WITH MANISCETOMY                           N     3
                      29881    2                      ARTHROSCOPY KNEE W MENISECTOMY INCL SHAVING                      N     3
                      29881    7                      ARTHROSCOPY KNEE W MENISECTOMY INCL SHAVING                      N     3
                      29881    8                      ARTHROSCOPY KNEE W/MENISECTOMY INC SHAVING                       N     3
                      29881    F                      ARTHROSCOPY KNEE W MENISECTOMY INCL SHAVING                      N     3
                      29882    2                      ARTHROSCOPY KNEE SURG W MENISCUS REPAIR M OR LAT                 N     3
                      29882    7                      ARTRSCPY KNE SURG W MEISC RPR MED OR LAT                         N     3
                      29882    8                      ARTHROSCOPY KNEE SURGERY W/MENISCUS REPAIR MEDIAL OR LATERAL     N     3
                      29882    F                      ARTHROSCOPY KNEE SURG W MENISCUS REPAIR M OR LAT                 N     3
                      29883    2                      ARTHROSCOPY, KNEE, SURGICAL                                      N     3
                      29883    7                      ARTHROSCOPY, KNEE, SURGICAL                                      N     3
                      29883    F                      ARTHROSCOPY, KNEE, SURGICAL                                      N     3
                      29884    2                      ARTHROSCOPY KNEE SURG W LYSIS ADNSNS W WO MANIP SP               N     3
                      29884    F                      ARTHROSCOPY KNEE SURG W LYSIS ADNSNS W WO MANIP SP               N     3
                      29885    2                      ARTHROSCOPY, KNEE, SURGICAL                                      N     3
                      29885    7                      ARTHROSCOPY, KNEE, SURGICAL                                      N     3




Updated: 09/22/2006                                                                                                               Page: 120 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      29885    F                      ARTHROSCOPY, KNEE, SURGICAL                                           N     3
                      29886    2                      ARTHROSCOPY KNEE SURG DRLLNG FOR INTCT OSTECHNDRTS                    N     3
                      29886    7                      ARTHROSCOPY KNEE SURG DRLLNG FOR INTCT OSTERCHNDRT                    N     3
                      29886    F                      ARTHROSCOPY KNEE SURG DRLLNG FOR INTCT OSTECHNDRTS                    N     3
                      29887    2                      ARTHROSCOPY KNEE SURG W DRLLNG FOR OST DESI INT FX                    N     3
                      29887    F                      ARTHROSCOPY KNEE SURG W DRLLNG FOR OST DESI INT FX                    N     3
                      29888    2                      ARTHROSCOPICALLT AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTA     N     3
                      29888    7                      RTHRSCPCLLY ADD NTRR CRCT LGMNT RPR/AGMNTTN OR REC                    N     3
                      29888    8                      ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTA     N     3
                      29888    F                      ARTHROSCOPICALLT AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTA     N     3
                      29889    2                      ARTHROSCOPICALLY AIDED POST CRUCIATE LIGAMENT REP                     N     3
                      29889    7                      ARTHROSCOPICALLY AIDED POST CRUCIATE LIGAMENT REP                     N     3
                      29889    8                      ARTHROSCOPICALLY AIDED POST CRUCIATE LIGAMENT REP                     N     3
                      29889    F                      ARTHROSCOPICALLY AIDED POST CRUCIATE LIGAMENT REP                     N     3
                      29891    2                      ARTHROSCOPY,ANKLE,SURG;EXCISION OF OSTEOCHONDRAL/INC.DRILL DEFECT     N     3
                      29891    7                      ARTHROSCOPY,ANKLE,SURG;EXCISION OF OSTEOCHONDRAL/INC.DRILL DEFECT     N     3
                      29891    8                      ARTHROSCOPY,ANKLE,SURG;EXCISION OF OSTEOCHONDRAL;INC.DRILL DEFECT     N     3
                      29891    F                      ARTHROSCOPY,ANKLE,SURG;EXCISION OF OSTEOCHONDRAL/INC.DRILL DEFECT     N     3
                      29892    2                      ARTHROSCOPICALLY REPAIR LG.OSTEOCHONDRITIS DISSECANS LESION           N     3
                      29892    7                      ARTHORSCOPICALLY REPAIR LG OSTEOCHONDRITIS DISSECANS LESION           N     3
                      29892    8                      ARTHROSCOPICALLY REPAIR LG.OSTEOCHONDRITIS DISSECANS LESION           N     3
                      29892    F                      ARTHROSCOPICALLY REPAIR LG.OSTEOCHONDRITIS DISSECANS LESION           N     3
                      29893    2                      ENDOSCOPIC PLANTAR FASIOTOMY                                          N     3
                      29893    7                      ENDOSCOPIC PLANTAR FASCIOTOMY                                         N     3
                      29893    8                      ENDOSCOPIC PLANTAR FASCIATOMY                                         N     3
                      29893    F                      ENDOSCOPIC PLANTAR FASIOTOMY                                          N     3
                      29894    2                      ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOI                    N     3
                      29894    7                      ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOI                    N     3
                      29894    8                      ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOI                    N     3
                      29894    F                      ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOI                    N     3
                      29895    2                      ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOI                    N     3
                      29895    7                      ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOI                    N     3
                      29895    8                      ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOI                    N     3
                      29895    F                      ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOI                    N     3
                      29897    2                      ARTHROSCOPY/SURGICAL/ANKLE                                            N     3
                      29897    7                      ARTHROSCOPY/SURGICAL/ANKLE                                            N     3
                      29897    8                      ARTHROSCOPY/SURGICAL/ANKLE - ASSISTANT                                N     3
                      29897    F                      ARTHROSCOPY/SURGICAL/ANKLE                                            N     3
                      29898    2                      ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOI                    N     3
                      29898    7                      ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOI                    N     3
                      29898    F                      ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOI                    N     3
                      29899    2                      ARTHROSCOPY ANKLE(TIBIOTALAR&FIBULOTALAR JOINTS)SURG                  N     3
                      29899    4                      ARTHROSCOPY ANKLE(TIBIOTALAR&FIBULOTALAR JOINTS)SURG                  N     3
                      29900    2                      ARTHROXCOPY METACARPOPHALANGEAL JOINT, DIAG, INC SYNOVIAL BIOPSY      N     3
                      29900    F                      ARTHROXCOPY METACARPOPHALANGEAL JOINT, DIAG, INC SYNOVIAL BIOPSY      N     3
                      29901    2                      ARTHROXCOPY METARPOPHALANGEAL JOINT SURGICAL, WITH DEBRIDEMENT        N     3
                      29901    F                      ARTHROXCOPY METARPOPHALANGEAL JOINT SURGICAL, WITH DEBRIDEMENT        N     3




Updated: 09/22/2006                                                                                                                    Page: 121 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                             PA IND PAC
                      29902    2                      ARTHROXCOPY METACARPOPHALANGEAL JOINT, SURGICAL, WITH REDUCTION     N     3
                      29902    F                      ARTHROXCOPY METACARPOPHALANGEAL JOINT, SURGICAL, WITH REDUCTION     N     3
                      29909    7                      UNLISTED PROC ARTHROSCOPY                                           N     3
                      30000    2                      DRAINAGE ABSCESS OR HEMATOMA, NASAL, INTERNAL APPR                  N     3
                      30000    7                      DRAINAGE ABSCESS OR HEMATOMA, NASAL, INTERNAL APPR                  N     3
                      30020    2                      DRAINAGE ABSCESS OR HEMATOMA, NASAL SEPTUM                          N     3
                      30020    7                      DRAINAGE ABSCESS OR HEMATOMA, NASAL SEPTUM                          N     3
                      30100    2                      BIOPSY, INTRANASAL                                                  N     3
                      30100    7                      BIOPSY, INTRANASAL                                                  N     3
                      30110    2                      EXCISION, NASAL POLYP(S), SIMPLE; UNILATERAL                        N     3
                      30110    7                      EXCISION, NASAL POLYP(S), SIMPLE; UNILATERAL                        N     3
                      30115    2                      EXCISION, NASAL POLYP(S), EXTENSIVE, UNILAT                         N     3
                      30115    7                      EXCISION, NASAL POLYP(S), EXTENSIVE; UNILATERAL                     N     3
                      30115    F                      EXCISION, NASAL POLYP(S), EXTENSIVE, UNILAT                         N     3
                      30117    2                      EXCISION, INTRANASAL LESION; INTERNAL APPROACH                      N     3
                      30117    7                      EXCISION, INTRANASAL LESION; INTERNAL APPROACH                      N     3
                      30117    F                      EXCISION, INTRANASAL LESION; INTERNAL APPROACH                      N     3
                      30118    2                      EXCISION, INTRANASAL LESION; EXTERNAL APPROACH                      N     3
                      30118    7                      EXCISION, INTRANASAL LESION; EXTERNAL APPROACH                      N     3
                      30118    F                      EXCISION, INTRANASAL LESION; EXTERNAL APPROACH                      N     3
                      30120    2                      EXCISION OR SURGICAL PLANING OF SKIN OF NOSE FOR R                  N     3
                      30120    7                      EXCISION OR SURGICAL PLANING OF SKIN OF NOSE FOR R                  N     3
                      30120    F                      EXCISION OR SURGICAL PLANING OF SKIN OF NOSE FOR R                  N     3
                      30124    2                      EXCISION DERMOID CYST, NOSE; SIMPLE, SKIN, SUBCUTA                  N     3
                      30125    2                      EXCISION DERMOID CYST, NOSE; COMPLEX, UNDER BONE O                  N     3
                      30125    7                      EXCISION DERMOID CYST, NOSE; COMPLEX, UNDER BONE O                  N     3
                      30125    F                      EXCISION DERMOID CYST, NOSE; COMPLEX, UNDER BONE O                  N     3
                      30130    2                      EXCISION TURBINATE, PARTIAL OR COMPLETE                             N     3
                      30130    7                      EXCISION TURBINATE, PARTIAL OR COMPLETE                             N     3
                      30130    F                      EXCISION TURBINATE, PARTIAL OR COMPLETE                             N     3
                      30140    2                      SUBMUCOUS RESECTION TURBINATE, PARTIAL OR COMPLETE                  N     3
                      30140    7                      SUBMUCOUS RESECTION TURBINATE, PARTIAL OR COMPLETE                  N     3
                      30140    F                      SUBMUCOUS RESECTION TURBINATE, PARTIAL OR COMPLETE                  N     3
                      30150    2                      RHINECTOMY; PARTIAL                                                 N     3
                      30150    7                      RHINECTOMY; PARTIAL                                                 N     3
                      30150    F                      RHINECTOMY; PARTIAL                                                 N     3
                      30160    2                      RHINECTOMY; TOTAL                                                   N     3
                      30160    7                      RHINECTOMY; TOTAL                                                   N     3
                      30160    8                      RHINECTOMY; TOTAL                                                   N     3
                      30160    F                      RHINECTOMY; TOTAL                                                   N     3
                      30200    2                      INJECTION INTO TURBINATE(S), THERAPEUTIC                            N     3
                      30210    2                      DISPLACEMENT THERAPY (PROETZ TYPE)                                  N     3
                      30220    2                      INSERTION NASAL SEPTAL PROSTHESIS(BUTTON)                           N     3
                      30220    7                      INSERTION NASAL SEPTAL PROSTHESIS(BUTTON)                           N     3
                      30230    7                      ENDOSCOPY                                                           N     3
                      30300    2                      REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROC                  N     3
                      30310    2                      REMOVAL FOREIGN BODY, INTRANASAL; REQUIRING GENERA                  N     3




Updated: 09/22/2006                                                                                                                  Page: 122 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      30310    7                      REMOVAL FOREIGN BODY, INTRANASAL; REQUIRING GENERA                    N     3
                      30310    F                      REMOVAL FOREIGN BODY, INTRANASAL; REQUIRING GENERA                    N     3
                      30320    2                      REMOVAL FOREIGN BODY, INTRANASAL; BY LATERAL RHINO                    N     3
                      30320    7                      REMOVAL FOREIGN BODY, INTRANASAL; BY LATERAL RHINO                    N     3
                      30320    F                      REMOVAL FOREIGN BODY, INTRANASAL; BY LATERAL RHINO                    N     3
                      30400    2                      RHINOPLASTY, PRIMARY; LATERAL AND ALAR CARTILAGES                     N     3
                      30400    7                      RHINOPLASTY, PRIMARY; LATERAL AND ALAR CARTILAGES                     N     3
                      30400    F                      RHINOPLASTY, PRIMARY; LATERAL AND ALAR CARTILAGES                     N     3
                      30410    2                      RHINOPLASTY, PRIMARY; COMPLETE, EXT INCL BONY PYRA                    N     3
                      30410    7                      RHINOPLASTY, PRIMARY; COMPLETE, EXT INCL BONY PYRA                    N     3
                      30410    F                      RHINOPLASTY, PRIMARY; COMPLETE, EXT INCL BONY PYRA                    N     3
                      30420    2                      RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAI                    N     3
                      30420    7                      RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAI                    N     3
                      30420    F                      RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAI                    N     3
                      30430    2                      RHINOPLASTY, SECONDARY; MINOR REVISION                                N     3
                      30430    F                      RHINOPLASTY, SECONDARY; MINOR REVISION                                N     3
                      30450    2                      RHINOPLASTY, SECONDARY; MAJOR REVISION                                N     3
                      30450    F                      RHINOPLASTY, SECONDARY; MAJOR REVISION                                N     3
                      30460    2                      RHINOPLASTY FOR NASAL DEFORMITY SECONDARY TO CONGE                    N     3
                      30460    7                      RHINOPLASTY NASAL DEFORMITY 2ND TO CONGENITAL CLEF                    N     3
                      30460    F                      RHINOPLASTY FOR NASAL DEFORMITY SECONDARY TO CONGE                    N     3
                      30462    2                      RHINOPLASTY FOR NASAL DEFORMITY 2ND TO CLEFT LIP                      N     3
                      30462    7                      RHINOPLASTY NASAL DEFORMITY 2ND TO CONGE CLEFT TIP                    N     3
                      30462    F                      RHINOPLASTY FOR NASAL DEFORMITY 2ND TO CLEFT LIP                      N     3
                      30465    2                      REPAIR OF NASAL VESTIB.STENOSIS SPREAD.GRAFTING,LAT.NASAL WLL.REC     N     3
                      30465    F                      REPAIR OF NASAL VESTIB.STENOSIS SPREAD.GRAFTING,LAT.NASAL WLL.REC     N     3
                      30500    2                      SUBMUCOUS RESECTION NASAL SEPTUM, CLASSIC                             N     3
                      30500    7                      SUBMUCOUS RESECTION NASAL SEPTUM, CLASSIC                             N     3
                      30500    8                      SUBMUCOUS RESECTION NASAL SEPTUM, CLASSIC                             N     3
                      30520    2                      SEPTOPLASTY WITH OR WITHOUT CARTILAGE IMPLANT (SEP                    N     3
                      30520    7                      SEPTOPLASTY WITH OR WITHOUT CARTILAGE IMPLANT (SEP                    N     3
                      30520    8                      SEPTOPLASTY WITH OR WITHOUT CARTILAGE IMPLANT (SEP                    N     3
                      30520    F                      SEPTOPLASTY WITH OR WITHOUT CARTILAGE IMPLANT (SEP                    N     3
                      30540    2                      REPAIR CHOANAL ATRESIA; INTRANASAL                                    N     3
                      30540    7                      REPAIR CHOANAL ATRESIA; INTRANASAL                                    N     3
                      30540    8                      REPAIR CHOANAL ATRESIA; INTRANASAL                                    N     3
                      30540    F                      REPAIR CHOANAL ATRESIA; INTRANASAL                                    N     3
                      30545    2                      REPAIR CHOANAL ATRESIA; TRANSPALATINE                                 N     3
                      30545    7                      REPAIR CHOANAL ATRESIA; TRANSPALATINE                                 N     3
                      30545    8                      REPAIR CHOANAL ATRESIA; TRANSPALATINE                                 N     3
                      30545    F                      REPAIR CHOANAL ATRESIA; TRANSPALATINE                                 N     3
                      30560    2                      LYSIS INTRANASAL SYNECHIA                                             N     3
                      30560    7                      LYSIS INTRANASAL SYNECHIA                                             N     3
                      30560    F                      LYSIS INTRANASAL SYNECHIA                                             N     3
                      30580    2                      REPAIR FISTULA; OROMAXILLARY                                          N     3
                      30580    7                      REPAIR FISTULA; OROMAXILLARY                                          N     3
                      30580    8                      REPAIR FISTULA; OROMAXILLARY                                          N     3




Updated: 09/22/2006                                                                                                                    Page: 123 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      30580    F                      REPAIR FISTULA; OROMAXILLARY                           N     3
                      30600    2                      REPAIR FISTULA; ORONASAL                               N     3
                      30600    7                      REPAIR FISTULA; ORONASAL                               N     3
                      30600    F                      REPAIR FISTULA; ORONASAL                               N     3
                      30620    2                      RECONSTRUCTION, FUNCTIONAL, INTERNAL NOSE (SEPTAL      N     3
                      30620    7                      RECONSTRUCTION, FUNCTIONAL, INTERNAL NOSE (SEPTAL      N     3
                      30620    8                      RECONSTRUCTION, FUNCTIONAL, INTERNAL NOSE (SEPTAL      N     3
                      30620    F                      RECONSTRUCTION, FUNCTIONAL, INTERNAL NOSE (SEPTAL      N     3
                      30630    2                      REPAIR NASAL SEPTAL PERFORATIONS                       N     3
                      30630    7                      REPAIR NASAL SEPTAL PERFORATIONS                       N     3
                      30630    8                      REPAIR NASAL SEPTAL PERFORATIONS                       N     3
                      30630    F                      REPAIR NASAL SEPTAL PERFORATIONS                       N     3
                      30801    2                      DESTRUCTION                                            N     3
                      30801    7                      DESTRUCTION                                            N     3
                      30801    F                      DESTRUCTION                                            N     3
                      30802    2                      CAUTERIZATION AND/OR ABLATION, MUCOSA OF TURBINATE     N     3
                      30802    7                      CAUTERIZATION AND/OR ABLATION, MUCOSA OF TURBINATE     N     3
                      30802    F                      CAUTERIZATION AND/OR ABLATION, MUCOSA OF TURBINATE     N     3
                      30901    2                      CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE(CAUTERIZA     N     3
                      30901    7                      CONTROL NASAL HEMORRHAGE ANTERIOR ANTERIOR SIMPLE      N     3
                      30903    2                      CONTROL NASAL HEMORRHAGE,COMPLEX(CAUTERIZATION WIT     N     3
                      30903    7                      CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX              N     3
                      30903    F                      CONTROL NASAL HEMORRHAGE,COMPLEX(CAUTERIZATION WIT     N     3
                      30905    2                      CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIO     N     3
                      30905    7                      CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIO     N     3
                      30905    F                      CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIO     N     3
                      30906    2                      CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIO     N     3
                      30906    7                      CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIO     N     3
                      30906    F                      CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIO     N     3
                      30915    2                      LIGATION ARTERIES; ETHMOIDAL                           N     3
                      30915    7                      LIGATION ARTERIES; ETHMOIDAL                           N     3
                      30915    8                      LIGATION ARTERIES; ETHMOIDAL                           N     3
                      30915    F                      LIGATION ARTERIES; ETHMOIDAL                           N     3
                      30920    2                      LIGATION ARTERIES; INTERNAL MAXILLARY ARTERY, TRAN     N     3
                      30920    7                      LIGATION ARTERIES; INTERNAL MAXILLARY ARTERY, TRAN     N     3
                      30920    8                      LIGATION ARTERIES; INTERNAL MAXILLARY ARTERY, TRAN     N     3
                      30920    F                      LIGATION ARTERIES; INTERNAL MAXILLARY ARTERY, TRAN     N     3
                      30930    2                      FRACTURE NASAL TURBINATE(S),THERAPEUTIC                N     3
                      30930    7                      FRACTURE NASAL TURBINATE(S),THERAPEUTIC                N     3
                      30930    F                      FRACTURE NASAL TURBINATE(S),THERAPEUTIC                N     3
                      30999    7                      UNLISTED PROCEDURE, NOSE                               N     3
                      31000    2                      LAVAGE BY CANNULATION; MAXILLARY SINUS UNILAT          N     3
                      31000    7                      LAVAGE BY CANNULATION; MAXILLARY SINUS, UNILATERAL     N     3
                      31002    2                      LAVAGE BY CANNULATION; SPHENOID SINUS                  N     3
                      31002    7                      LAVAGE BY CANNULATION; SPHENOID SINUS                  N     3
                      31020    2                      SINUSOTOMY, MAXILLARY (ANTROTOMY); INTRANASAL, UNI     N     3
                      31020    7                      SINUSOTOMY, MAXILLARY (ANTROTOMY); INTRANASAL, UNI     N     3




Updated: 09/22/2006                                                                                                     Page: 124 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      31020    F                      SINUSOTOMY, MAXILLARY (ANTROTOMY); INTRANASAL, UNI     N     3
                      31030    2                      SINUSOTOMY, MAXILLARY (ANTROTOMY); RADICAL UNILAT      N     3
                      31030    7                      SINUSOTOMY,MAXILLARY(ANTROTOMY);RADICAL,UNILATERAL     N     3
                      31030    8                      SINUSOTOMY,MAXILLARY(ANTROTOMY);RADICAL,UNILATERAL     N     3
                      31030    F                      SINUSOTOMY, MAXILLARY (ANTROTOMY); RADICAL UNILAT      N     3
                      31031    7                      SINUSOTOMY,MAXILLARY(ANTROTOMY);RADICAL,BILATERAL      N     3
                      31032    2                      SINUSTOMY,MAXILLARY;RADICAL UNILATERAL (CALDWELL-L     N     3
                      31032    7                      SINUSTOMY,MAXILLARY;RADICAL UNILATERAL (CALDWELL-L     N     3
                      31032    8                      SINUSTOMY,MAXILLARY;RADICAL UNILATERAL (CALDWELL-L     N     3
                      31032    F                      SINUSTOMY,MAXILLARY;RADICAL UNILATERAL (CALDWELL-L     N     3
                      31040    2                      SURGERY ON PTERYGOMAXILLARY FOSSA CONTENTS BY TRAN     N     3
                      31040    7                      SURGERY ON PTERYGOMAXILLARY FOSSA CONTENTS BY TRAN     N     3
                      31050    2                      SINUSOTOMY, SPHENOID                                   N     3
                      31050    7                      SINUSOTOMY, SPHENOID                                   N     3
                      31050    8                      SINUSOTOMY, SPHENOID                                   N     3
                      31050    F                      SINUSOTOMY, SPHENOID                                   N     3
                      31051    2                      SNSTMY SPHND W MCSL STPPING OR RMVL OF POLYP(S)        N     3
                      31051    7                      SNSTMY SPHND W MCSL STPPING OR RMVL OF POLYP(S)        N     3
                      31051    8                      SNSTMY SPHND W MCSL STPPING OR RMVL OF POLYP(S)        N     3
                      31051    F                      SNSTMY SPHND W MCSL STPPING OR RMVL OF POLYP(S)        N     3
                      31070    2                      SINUSOTOMY FRONTAL; EXTERNAL, SIMPLE                   N     3
                      31070    7                      SINUSOTOMY FRONTAL; EXTERNAL, SIMPLE                   N     3
                      31070    8                      SINUSOTOMY FRONTAL; EXTERNAL, SIMPLE                   N     3
                      31070    F                      SINUSOTOMY FRONTAL; EXTERNAL, SIMPLE                   N     3
                      31075    2                      SINUSOTOMY FRONTAL; TRANSORBITAL, UNILATERAL           N     3
                      31075    7                      SINUSOTOMY FRONTAL; TRANSORBITAL, UNILATERAL           N     3
                      31075    8                      SINUSOTOMY FRONTAL; TRANSORBITAL, UNILATERAL           N     3
                      31075    F                      SINUSOTOMY FRONTAL; TRANSORBITAL, UNILATERAL           N     3
                      31080    2                      SINUSOTOMY FRONTAL;OBLITERATIVE WITHOUT OSTEOPLAST     N     3
                      31080    7                      SINUSOTOMY FRONTAL;OBLITERATIVE WITHOUT OSTEOPLAST     N     3
                      31080    F                      SINUSOTOMY FRONTAL;OBLITERATIVE WITHOUT OSTEOPLAST     N     3
                      31081    2                      SINUSOTOMY FRONTAL;OBLITERATIVE W/O OSTEOPLASTIC F     N     3
                      31081    7                      SINUSOTOMY FRONTAL;OBLITERATIVE W/O OSTEOPLASTIC F     N     3
                      31081    F                      SINUSOTOMY FRONTAL;OBLITERATIVE W/O OSTEOPLASTIC F     N     3
                      31084    2                      SINUSOTOMY FRONTAL; OBLITERATIVE, WITH OSTEOPLASTI     N     3
                      31084    7                      SINUSOTOMY FRONTAL; OBLITERATIVE, WITH OSTEOPLASTI     N     3
                      31084    8                      SINUSOTOMY FRONTAL; OBLITERATIVE, WITH OSTEOPLASTI     N     3
                      31084    F                      SINUSOTOMY FRONTAL; OBLITERATIVE, WITH OSTEOPLASTI     N     3
                      31085    2                      SINUSOTOMY FRONTAL; OBLITERATIVE, WITH OSTEOPLASTI     N     3
                      31085    7                      SINUSOTOMY FRONTAL; OBLITERATIVE, WITH OSTEOPLASTI     N     3
                      31085    8                      SINUSOTOMY FRONTAL; OBLITERATIVE, WITH OSTEOPLASTI     N     3
                      31085    F                      SINUSOTOMY FRONTAL; OBLITERATIVE, WITH OSTEOPLASTI     N     3
                      31086    2                      SINUSOTOMY FRONTAL; NONOBLITERATIVE, WITH OSTEOPLA     N     3
                      31086    F                      SINUSOTOMY FRONTAL; NONOBLITERATIVE, WITH OSTEOPLA     N     3
                      31087    2                      SINUSOTOMY FRONTAL; NONOBLITERATIVE, WITH OSTEOPLA     N     3
                      31087    F                      SINUSOTOMY FRONTAL; NONOBLITERATIVE, WITH OSTEOPLA     N     3
                      31090    2                      SINUSOTOMY COMBINED, THREE OR MORE SINUSES             N     3




Updated: 09/22/2006                                                                                                     Page: 125 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                           PA IND PAC
                      31090    7                      SINUSOTOMY COMBINED, THREE OR MORE SINUSES                        N     3
                      31090    8                      SINUSOTOMY COMBINED, THREE OR MORE SINUSES                        N     3
                      31090    F                      SINUSOTOMY COMBINED, THREE OR MORE SINUSES                        N     3
                      31200    2                      ETHMOIDECTOMY; INTRANASAL, ANTERIOR                               N     3
                      31200    7                      ETHMOIDECTOMY; INTRANASAL, ANTERIOR                               N     3
                      31200    8                      ETHMOIDECTOMY; INTRANASAL, ANTERIOR                               N     3
                      31200    F                      ETHMOIDECTOMY; INTRANASAL, ANTERIOR                               N     3
                      31201    2                      ETHMOIDECTOMY; INTRANASAL, TOTAL                                  N     3
                      31201    7                      ETHMOIDECTOMY; INTRANASAL, TOTAL                                  N     3
                      31201    8                      ETHMOIDECTOMY; INTRANASAL, TOTAL                                  N     3
                      31201    F                      ETHMOIDECTOMY; INTRANASAL, TOTAL                                  N     3
                      31205    2                      ETHMOIDECTOMY; EXTRANASAL, TOTAL                                  N     3
                      31205    7                      ETHMOIDECTOMY; EXTRANASAL, TOTAL                                  N     3
                      31205    8                      ETHMOIDECTOMY; EXTRANASAL, TOTAL                                  N     3
                      31205    F                      ETHMOIDECTOMY; EXTRANASAL, TOTAL                                  N     3
                      31225    2                      MAXILLECTOMY; WITHOUT ORBITAL EXENTERATION                        N     3
                      31225    7                      MAXILLECTOMY; WITHOUT ORBITAL EXENTERATION                        N     3
                      31225    8                      MAXILLECTOMY; WITHOUT ORBITAL EXENTERATION                        N     3
                      31230    2                      MAXILLECTOMY; WITH ORBITAL EXENTERATION                           N     3
                      31230    7                      MAXILLECTOMY; WITH ORBITAL EXENTERATION                           N     3
                      31230    8                      MAXILLECTOMY; WITH ORBITAL EXENTERATION                           N     3
                      31231    2                      NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL OR BILATER                N     3
                      31231    7                      NASAL ENDOSCOPY, DIAG, UNILATERAL OR BILATERAL                    N     3
                      31233    2                      NASAL/SINUS ENDOSCOPY, DIAGNOSTIC WITH MAXILLARY S                N     3
                      31233    7                      ANESTHESIA,NASAL/SINUS ENDOSCOPY, DIAGNOSTIC WITH MAXILLARY S     N     3
                      31233    F                      NASAL/SINUS ENDOSCOPY, DIAGNOSTIC WITH MAXILLARY S                N     3
                      31235    2                      NASAL/SINUS ENDOSCOPY, DIAGNOSTIC WITH SPHENOID SI                N     3
                      31235    F                      NASAL/SINUS ENDOSCOPY, DIAGNOSTIC WITH SPHENOID SI                N     3
                      31237    2                      NASAL/SINUS ENDOSCOPY, SURGICAL;                                  N     3
                      31237    7                      NASAL/SINUS ENDOSCOPY                                             N     3
                      31237    F                      NASAL/SINUS ENDOSCOPY, SURGICAL;                                  N     3
                      31238    2                      NASAL/SINUS ENDOSCOPY, SURGICAL;                                  N     3
                      31238    7                      NASAL/SINUS ENDOSCOPY,SURGICAL                                    N     3
                      31238    F                      NASAL/SINUS ENDOSCOPY, SURGICAL;                                  N     3
                      31239    2                      NASAL/SINUS ENDOSCOPY, SURGICAL;                                  N     3
                      31239    8                      NASAL/SINUS ENDOSCOPY, SURGICAL                                   N     3
                      31239    F                      NASAL/SINUS ENDOSCOPY, SURGICAL;                                  N     3
                      31240    2                      NASAL/SINUS ENDOSCOPY, SURGICAL;                                  N     3
                      31240    F                      NASAL/SINUS ENDOSCOPY, SURGICAL;                                  N     3
                      31254    2                      NASAL ENDO SURG W ETHMOIDECTOMY PARTIAL                           N     3
                      31254    7                      NASAL ENDO SURG W/ETHMOIDECTOMY PARTIAL                           N     3
                      31254    F                      NASAL ENDO SURG W ETHMOIDECTOMY PARTIAL                           N     3
                      31255    2                      ENDOSCOPY WITH ETHMOIDECTOMY, TOTAL (ANTERIOR AND POSTERIOR)      N     3
                      31255    3                      NASAL ENDO W ETHMOIDECTOMY ANT - POST TOTAL                       N     3
                      31255    7                      ENDOSCOPY WITH ETHMOIDECTOMY, TOTAL (ANTERIOR AND POSTERIOR)      N     3
                      31255    F                      ENDOSCOPY WITH ETHMOIDECTOMY, TOTAL (ANTERIOR AND POSTERIOR)      N     3
                      31256    2                      NASAL ENDOSCOPY-SURGICAL WITH MAXILLARY ANTROSTOMY                N     3




Updated: 09/22/2006                                                                                                                Page: 126 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                            PA IND PAC
                      31256    7                      NASAL ENDOSCOPY-SURGICAL WITH MAXILLARY ANTROSTOMY                 N     3
                      31256    F                      NASAL ENDOSCOPY-SURGICAL WITH MAXILLARY ANTROSTOMY                 N     3
                      31267    2                      NASAL SINUS ENDOSCOPY, REMOVAL OF TISSUE FROM MAXILLARY SINUS      N     3
                      31267    7                      ANESTHESIA- NASAL SINUS ENDOSCOPY                                  N     3
                      31267    F                      NASAL SINUS ENDOSCOPY, REMOVAL OF TISSUE FROM MAXILLARY SINUS      N     3
                      31276    2                      NASAL/SINUS ENDOSCOPY, SURGICAL WITH FRONTAL SINUS EXPLORATION     N     3
                      31276    F                      NASAL/SINUS ENDOSCOPY, SURGICAL WITH FRONTAL SINUS EXPLORATION     N     3
                      31287    2                      NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOM                 N     3
                      31287    F                      NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOM                 N     3
                      31288    2                      NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOM                 N     3
                      31288    F                      NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOM                 N     3
                      31290    2                      NASAL/SINUS ENDOSCOPY, SURGICAL, WITH REPAIR OF CE                 N     3
                      31291    2                      NASAL/SINUS ENDOSCOPY, SURGICAL, WITH REPAIR OF CE                 N     3
                      31292    2                      NASAL/SINUS ENDOSCOPY, SURGICAL;                                   N     3
                      31293    2                      NASAL/SINUS ENDOSCOPY, SURGICAL;                                   N     3
                      31294    2                      NASAL/SINUS ENDOSCOPY, SURGICAL;                                   N     3
                      31299    7                      UNLISTED PROCEDURE, ACCESSORY SINUSES                              N     3
                      31300    2                      LARYNGOTOMY (THYROTOMY, LARYNGOFISSURE); WITH REMO                 N     3
                      31300    7                      LARYNGOTOMY (THYROTOMY, LARYNGOFISSURE); WITH REMO                 N     3
                      31300    8                      LARYNGOTOMY (THYROTOMY, LARYNGOFISSURE); WITH REMO                 N     3
                      31300    F                      LARYNGOTOMY (THYROTOMY, LARYNGOFISSURE); WITH REMO                 N     3
                      31320    2                      LARYNGOTOMY (THYROTOMY, LARYNGOFISSURE); DIAGNOSTI                 N     3
                      31320    7                      LARYNGOTOMY (THYROTOMY, LARYNGOFISSURE); DIAGNOSTI                 N     3
                      31320    F                      LARYNGOTOMY (THYROTOMY, LARYNGOFISSURE); DIAGNOSTI                 N     3
                      31360    2                      LARYNGECTOMY; TOTAL, WITHOUT RADICAL NECK DISSECTI                 N     3
                      31360    7                      LARYNGECTOMY; TOTAL, WITHOUT RADICAL NECK DISSECTI                 N     3
                      31360    8                      LARYNGECTOMY; TOTAL, WITHOUT RADICAL NECK DISSECTI                 N     3
                      31365    2                      LARYNGECTOMY; TOTAL, WITH RADICAL NECK DISSECTION                  N     3
                      31365    7                      LARYNGECTOMY; TOTAL, WITH RADICAL NECK DISSECTION                  N     3
                      31365    8                      LARYNGECTOMY; TOTAL, WITH RADICAL NECK DISSECTION                  N     3
                      31367    2                      LARYNGECTOMY; SUBTOTAL SUPRAGLOTTIC, WITHOUT RADIC                 N     3
                      31367    7                      LARYNGECTOMY; SUBTOTAL SUPRAGLOTTIC, WITHOUT RADIC                 N     3
                      31368    2                      LARYNGECTOMY; SUBTOTAL SUPRAGLOTTIC, WITH RADICAL                  N     3
                      31368    7                      LARYNGECTOMY; SUBTOTAL SUPRAGLOTTIC, WITH RADICAL                  N     3
                      31368    8                      LARYNGECTOMY; SUBTOTAL SUPRAGLOTTIC, WITH RADICAL                  N     3
                      31370    2                      PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY); HORIZONTA                 N     3
                      31370    7                      PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY); HORIZONTA                 N     3
                      31370    8                      PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY); HORIZONTA                 N     3
                      31375    2                      PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY); LATEROVER                 N     3
                      31375    7                      PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY); LATEROVER                 N     3
                      31375    8                      PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY); LATEROVER                 N     3
                      31380    2                      PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY); ANTEROVER                 N     3
                      31380    7                      PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY); ANTEROVER                 N     3
                      31380    8                      PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY); ANTEROVER                 N     3
                      31382    2                      PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY); ANTERO-LA                 N     3
                      31382    7                      PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY); ANTERO-LA                 N     3
                      31390    2                      PHARYNGOLARYNGECTOMY, WITH RADICAL NECK DISSECTION                 N     3




Updated: 09/22/2006                                                                                                                 Page: 127 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      31390    7                      PHARYNGOLARYNGECTOMY, WITH RADICAL NECK DISSECTION     N     3
                      31390    8                      PHARYNGOLARYNGECTOMY, WITH RADICAL NECK DISSECTION     N     3
                      31395    2                      PHARYNGOLARYNGECTOMY, WITH RADICAL NECK DISSECTION     N     3
                      31395    7                      PHARYNGOLARYNGECTOMY, WITH RADICAL NECK DISSECTION     N     3
                      31400    2                      ARYTENOIDECTOMY OR ARYTENOIDOPEXY, EXTERNAL APPROA     N     3
                      31400    7                      ARYTENOIDECTOMY OR ARYTENOIDOPEXY, EXTERNAL APPROA     N     3
                      31400    8                      ARYTENOIDECTOMY OR ARYTENOIDOPEXY, EXTERNAL APPROA     N     3
                      31400    F                      ARYTENOIDECTOMY OR ARYTENOIDOPEXY, EXTERNAL APPROA     N     3
                      31420    2                      EPIGLOTTIDECTOMY                                       N     3
                      31420    7                      EPIGLOTTIDECTOMY                                       N     3
                      31420    8                      EPIGLOTTIDECTOMY                                       N     3
                      31420    F                      EPIGLOTTIDECTOMY                                       N     3
                      31500    2                      INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE          N     3
                      31500    7                      INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE          N     3
                      31502    2                      TRACHEOTOMY TUBE CHANGE PRIOR TO ESTABLISHMENT OF      N     3
                      31502    7                      TRACHEOTOMY TUBE CHANGE PRIOR TO ESTABLISHMENT OF      N     3
                      31505    2                      LARYNGOSCOPY, INDIRECT (SEPARATE PROCEDURE); DIAGN     N     3
                      31505    7                      LARYNGOSCOPY, INDIRECT (SEPARATE PROCEDURE); DIAGN     N     3
                      31510    2                      LARYNGOSCOPY, INDIRECT (SEPARATE PROCEDURE); WITH      N     3
                      31510    7                      LARYGOSCOPY INDIR SEP PROC WITH BIOPSY                 N     3
                      31510    F                      LARYNGOSCOPY, INDIRECT (SEPARATE PROCEDURE); WITH      N     3
                      31511    2                      LARYNGOSCOPY, INDIRECT (SEPARATE PROCEDURE); WITH      N     3
                      31511    7                      LARYNGOSCOPY, INDIRECT (SEPARATE PROCEDURE); WITH      N     3
                      31511    F                      LARYNGOSCOPY, INDIRECT (SEPARATE PROCEDURE); WITH      N     3
                      31512    2                      LARYNGOSCOPY, INDIRECT (SEPARATE PROCEDURE); WITH      N     3
                      31512    7                      LARYNGOSCOPY, INDIRECT (SEPARATE PROCEDURE); WITH      N     3
                      31512    F                      LARYNGOSCOPY, INDIRECT (SEPARATE PROCEDURE); WITH      N     3
                      31513    2                      LARYNGOSCOPY, INDIRECT (SEPARATE PROCEDURE); WITH      N     3
                      31513    7                      LARYNGOSCOPY, INDIRECT (SEPARATE PROCEDURE); WITH      N     3
                      31513    F                      LARYNGOSCOPY, INDIRECT (SEPARATE PROCEDURE); WITH      N     3
                      31515    2                      LARYNGOSCOPY DIRECT; FOR ASPIRATION                    N     3
                      31515    7                      LARYNGOSCOPY DIRECT FOR ASPIRATION                     N     3
                      31515    F                      LARYNGOSCOPY DIRECT; FOR ASPIRATION                    N     3
                      31520    2                      LARYNGOSCOPY DIRECT; DIAGNOSTIC, NEWBORN               N     3
                      31520    7                      LARYNGOSCOPY DIRECT; DIAGNOSTIC, NEWBORN               N     3
                      31525    2                      LARYNGOSCOPY DIRECT; DIAGNOSTIC, EXCEPT NEWBORN        N     3
                      31525    7                      LARYNGOSCOPY DIRECT; DIAGNOSTIC, EXCEPT NEWBORN        N     3
                      31525    F                      LARYNGOSCOPY DIRECT; DIAGNOSTIC, EXCEPT NEWBORN        N     3
                      31526    2                      LARYNGOSCOPY DIRECT; DIAGNOSTIC, WITH OPERATING MI     N     3
                      31526    7                      LARYNGOSCOPY DIRECT; DIAGNOSTIC, WITH OPERATING MI     N     3
                      31526    F                      LARYNGOSCOPY DIRECT; DIAGNOSTIC, WITH OPERATING MI     N     3
                      31527    2                      LARYNGOSCOPY DIRECT; WITH INSERTION OF OBTURATOR       N     3
                      31527    7                      LARYNGOSCOPY DIRECT; WITH INSERTION OF OBTURATOR       N     3
                      31527    F                      LARYNGOSCOPY DIRECT; WITH INSERTION OF OBTURATOR       N     3
                      31528    2                      LARYNGOSCOPY DIRECT; WITH DILATATION, INITIAL          N     3
                      31528    7                      LARYNGOSCOPY, DIRECT; WITH DILATATION, INITIAL         N     3
                      31528    F                      LARYNGOSCOPY DIRECT; WITH DILATATION, INITIAL          N     3




Updated: 09/22/2006                                                                                                     Page: 128 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      31529    2                      LARYNGOSCOPY, DIRECT; WITH DILATATION, SUBSEQUENT                     N     3
                      31529    7                      LARYNGOSCOPY, DIRECT; WITH DILATATION, SUBSEQUENT                     N     3
                      31529    F                      LARYNGOSCOPY, DIRECT; WITH DILATATION, SUBSEQUENT                     N     3
                      31530    2                      LARYNGOSCOPY, OPERATIVE, WITH FOREIGN BODY REMOVAL                    N     3
                      31530    7                      LARYNGOSCOPY, OPERATIVE, WITH FOREIGN BODY REMOVAL                    N     3
                      31530    F                      LARYNGOSCOPY, OPERATIVE, WITH FOREIGN BODY REMOVAL                    N     3
                      31531    2                      LARYNGOSCOPY, OPERATIVE, WITH FOREIGN BODY REMOVAL                    N     3
                      31531    7                      LARYNGOSCOPY, OPERATIVE, WITH FOREIGN BODY REMOVAL                    N     3
                      31531    F                      LARYNGOSCOPY, OPERATIVE, WITH FOREIGN BODY REMOVAL                    N     3
                      31535    2                      LARYNGOSCOPY, OPERATIVE, WITH BIOPSY;                                 N     3
                      31535    7                      LARYNGOSCOPY, OPERATIVE, WITH BIOPSY;                                 N     3
                      31535    F                      LARYNGOSCOPY, OPERATIVE, WITH BIOPSY;                                 N     3
                      31536    2                      LARYNGOSCOPY, OPERATIVE, WITH BIOPSY; WITH OPERATI                    N     3
                      31536    7                      LARYNGOSCOPY, OPERATIVE, WITH BIOPSY; WITH OPERATI                    N     3
                      31536    F                      LARYNGOSCOPY, OPERATIVE, WITH BIOPSY; WITH OPERATI                    N     3
                      31540    2                      LARYNGOSCOPY, OPERATIVE, WITH EXCISION OF TUMOR AN                    N     3
                      31540    7                      LARYNGOSCOPY, OPERATIVE, WITH EXCISION OF TUMOR AN                    N     3
                      31540    F                      LARYNGOSCOPY, OPERATIVE, WITH EXCISION OF TUMOR AN                    N     3
                      31541    2                      LARYNGOSCOPY, OPERATIVE, WITH EXCISION OF TUMOR AN                    N     3
                      31541    7                      LARYNGOSCOPY, OPERATIVE, WITH EXCISION OF TUMOR AN                    N     3
                      31541    F                      LARYNGOSCOPY, OPERATIVE, WITH EXCISION OF TUMOR AN                    N     3
                      31545    2                      LARYNGOSCOPY, DIRECT OPERATIVE WITH OPERATING MICROSCOPE OR TELES     N     3
                      31545    7                      LARYNGOSCOPY DIRECT OP WITH MICROSCOPE OR TELESCOPE                   N     3
                      31546    2                      LARYNGOSCOPY DIRECT OP WITH MICROSCOPE OR TELESCOPE                   N     3
                      31546    7                      LARYNGOSCOPY, DIR OPERATIVE WITH OPERATING MICROSCOPE OF TELESCOP     N     3
                      31560    2                      LARYNGOSCOPY, OPERATIVE, WITH ARYTENOIDECTOMY;                        N     3
                      31560    7                      LARYNGOSCOPY, OPERATIVE, WITH ARYTENOIDECTOMY;                        N     3
                      31560    F                      LARYNGOSCOPY, OPERATIVE, WITH ARYTENOIDECTOMY;                        N     3
                      31561    2                      LARYNGOSCOPY, OPERATIVE, WITH ARYTENOIDECTOMY; WIT                    N     3
                      31561    7                      LARYNGOSCOPY, OPERATIVE, WITH ARYTENOIDECTOMY; WIT                    N     3
                      31561    F                      LARYNGOSCOPY, OPERATIVE, WITH ARYTENOIDECTOMY; WIT                    N     3
                      31570    2                      LARYNGOSCOPY WITH INJECTION INTO VOCAL CORD(S), TH                    N     3
                      31570    7                      LARYNGOSCOPY WITH INJECTION INTO VOCAL CORD(S), TH                    N     3
                      31570    F                      LARYNGOSCOPY WITH INJECTION INTO VOCAL CORD(S), TH                    N     3
                      31571    2                      LARYNGOSCOPY WITH INJECTION INTO VOCAL CORD(S), TH                    N     3
                      31571    7                      LARYNGOSCOPY WITH INJECTION INTO VOCAL CORD(S), TH                    N     3
                      31571    F                      LARYNGOSCOPY WITH INJECTION INTO VOCAL CORD(S), TH                    N     3
                      31575    2                      LARYNGOSCOPY FLEXIBLE FIBERSCOPIC; DIAGNOSTIC                         N     3
                      31575    7                      LARYNGOSCOPY FLEXIBLE FIBERSCOPIC; DIAGNOSTIC                         N     3
                      31576    2                      LARYNGOSCOPY FLEXIBLE FIBERSCOPIC; WITH BIOPSY                        N     3
                      31576    7                      LARYNGOSCOPY FLEXIBLE FIBERSCOPIC; WITH BIOPSY                        N     3
                      31576    F                      LARYNGOSCOPY FLEXIBLE FIBERSCOPIC; WITH BIOPSY                        N     3
                      31577    2                      LARYNGOSCOPY, FLEXIBLE FIBERSCOPIC; WITH REMOVAL O                    N     3
                      31577    7                      LARYNGOSCOPY, FLEXIBLE FIBERSCOPIC; WITH REMOVAL O                    N     3
                      31577    F                      LARYNGOSCOPY, FLEXIBLE FIBERSCOPIC; WITH REMOVAL O                    N     3
                      31578    2                      LARYNGOSCOPY, FLEXIBLE FIBERSCOPIC; WITH REMOVAL O                    N     3
                      31578    7                      LARYNGOSCOPY, FLEXIBLE FIBERSCOPIC; WITH REMOVAL O                    N     3




Updated: 09/22/2006                                                                                                                    Page: 129 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                PA IND PAC
                      31578    F                      LARYNGOSCOPY, FLEXIBLE FIBERSCOPIC; WITH REMOVAL O     N     3
                      31579    2                      LARYNGOSCOPY, FLEX OR RIG FIBROPTIC, W/STROBOSCOPY     N     3
                      31579    7                      LARYNGOSCOPY, FLEXIBLE FIBEROPTIC                      N     3
                      31580    2                      LARYNGOPLASTY; FOR LARYNGEAL WEB, TWO STAGE, WITH      N     3
                      31580    7                      LARYNGOPLASTY; FOR LARYNGEAL WEB, TWO STAGE, WITH      N     3
                      31580    8                      LARYNGOPLASTY; FOR LARYNGEAL WEB, TWO STAGE, WITH      N     3
                      31580    F                      LARYNGOPLASTY; FOR LARYNGEAL WEB, TWO STAGE, WITH      N     3
                      31582    2                      LARYNGOPLASTY; FOR LARYNGEAL STENOSIS, WITH GRAFT      N     3
                      31582    7                      LARYNGOPLASTY; FOR LARYNGEAL STENOSIS, WITH GRAFT      N     3
                      31582    8                      LARYNGOPLASTY; FOR LARYNGEAL STENOSIS, WITH GRAFT      N     3
                      31582    F                      LARYNGOPLASTY; FOR LARYNGEAL STENOSIS, WITH GRAFT      N     3
                      31584    7                      LARYNGOPLASTY; WITH OPEN REDUCTION OF FRACTURE         N     3
                      31587    7                      LARYNGOPLASTY, CRICOID SPLIT                           N     3
                      31588    2                      LARYNGOPLASTY, NOT OTHERWISE SPECIFIED (EG, FOR BU     N     3
                      31588    7                      LARYNGOPLASTY, NOT OTHERWISE SPECIFIED (EG, FOR BU     N     3
                      31588    F                      LARYNGOPLASTY, NOT OTHERWISE SPECIFIED (EG, FOR BU     N     3
                      31590    2                      LARYNGEAL REINNERVATION BY NEUROMUSCULAR PEDICLE       N     3
                      31590    7                      LARYNGEAL REINNERVATION BY NEUROMUSCULAR PEDICLE       N     3
                      31590    8                      LARYNGEAL REINNERVATION BY NEUROMUSCULAR PEDICLE       N     3
                      31590    F                      LARYNGEAL REINNERVATION BY NEUROMUSCULAR PEDICLE       N     3
                      31595    7                      SECTIN RECURRENT LARYNGEAL NERVE THERAPEUTIC(SEPAR     N     3
                      31595    F                      SECTION RECURRENT LARYNGEAL NERVE THERAPEUTIC(SEPA     N     3
                      31599    7                      UNLISTED PROCEDURE, LARYNX                             N     3
                      31600    2                      TRACHEOSTOMY, PLANNED (SEPARATE PROCEDURE)             N     3
                      31600    7                      TRACHEOSTOMY, PLANNED (SEPARATE PROCEDURE)             N     3
                      31600    8                      TRACHEOSTOMY, PLANNED (SEPARATE PROCEDURE)             N     3
                      31601    2                      TRACHEOSTOMY, PLANNED (SEPARATE PROCEDURE); UNDER      N     3
                      31601    7                      TRACHEOSTOMY, PLANNED (SEPARATE PROCEDURE); UNDER      N     3
                      31603    2                      TRACHEOSTOMY EMERGENCY PEOCEDURE;TRANSTRACHEAL         N     3
                      31603    7                      TRACHEASTOMY EMERGENCY PROCEDURE;TRANSTRACHEAL         N     3
                      31603    8                      TRACHEOSTOMY EMERGENCY PROCEDURE;TRANSTRACHEAL         N     3
                      31605    2                      TRACHEOSTOMY; CRICOTHYROID MEMBRANE ACHE               N     3
                      31605    7                      TRACHEOSTOMY; CRICOTHYROID MEMBRANE REPA               N     3
                      31610    2                      TRACHEOSTOMY, FENESTRATION PROCEDURE WITH SKIN FLA     N     3
                      31610    7                      TRACHEOSTOMY, FENESTRATION PROCEDURE WITH SKIN FLA     N     3
                      31611    2                      CONSTRUCTION OF TRACHEOESOPHAGEAL FISTULA AND SUBS     N     3
                      31611    7                      CONSTRUCTION OF TRACHEOESOPHAGEAL FISTULA AND SUBS     N     3
                      31611    F                      CONSTRUCTION OF TRACHEOESOPHAGEAL FISTULA AND SUBS     N     3
                      31612    2                      TRACHEAL PUNCTURE, PERCUTANEOUS FOR ASPIRATION OF      N     3
                      31612    7                      TRACHEAL PUNCTURE, PERCUTANEOUS FOR ASPIRATION OF      N     3
                      31612    F                      TRACHEAL PUNCTURE, PERCUTANEOUS FOR ASPIRATION OF      N     3
                      31613    2                      TRACHEOSTOMA REVISION; SIMPLE WITHOUT FLAP ROTATIO     N     3
                      31613    7                      TRACHEASOTMA REVISION; SIMPLE WITHOUT FLAP ROTATIO     N     3
                      31613    F                      TRACHEOSTOMA REVISION; SIMPLE WITHOUT FLAP ROTATIO     N     3
                      31614    2                      TRACHEOSTOMA REVISION; COMPLEX, WITH FLAP ROTATION     N     3
                      31614    7                      TRACHEOSTOMA REVISION; COMPLEX, WITH FLAP ROTATION     N     3
                      31614    F                      TRACHEOSTOMA REVISION; COMPLEX, WITH FLAP ROTATION     N     3




Updated: 09/22/2006                                                                                                     Page: 130 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      31615    2                      TRACHEOSCOPY THROUGH ESTABLISHED TRACHEOSTOMY INCI                    N     3
                      31615    7                      TRACHEOSCOPY THROUGH ESTABLISHED TRACHEOSTOMY INCI                    N     3
                      31615    F                      TRACHEOSCOPY THROUGH ESTABLISHED TRACHEOSTOMY INCI                    N     3
                      31620    2                      ENDOBRONCHIAL ULTRASOUND                                              N     3
                      31620    7                      ENDOBRONCHIAL ULTRASOUND                                              N     3
                      31621    7                      BRONCHOSCOPY; DIAGNOSTIC, FIBEROPTIC BRONCHOSCOPE                     N     3
                      31622    2                      BRONCHOSCOPY DIAG FLX OR RIGD W W/O CL WASH OR BRS                    N     3
                      31622    7                      BRONCHOSCOPY DIAGNOSTIC FLEX OR RIGID-ANESTHESIA                      N     3
                      31622    F                      BRONCHOSCOPY DIAG FLX OR RIGD W W/O CL WASH OR BRS                    N     3
                      31623    2                      BRONCHOSCOPY W/BRUSHING OR PROTECTED BRUSHINGS                        N     3
                      31623    F                      BRONCHOSCOPY W/BRUSHING OR PROTECTED BRUSHINGS                        N     3
                      31624    2                      BRONCHOSCOPY W/BRONCHIAL ALVEOLAR LAVAGE                              N     3
                      31624    F                      BRONCHOSCOPY W/BRONCHIAL ALVEOLAR LAVAGE                              N     3
                      31625    2                      BRONCHOSCOPY; WITH BIOPSY, RIGID BRONCHOSCOPE                         N     3
                      31625    7                      BRONCHOSCOPY; WITH BIOPSY, RIGID BRONCHOSCOPE                         N     3
                      31625    F                      BRONCHOSCOPY; WITH BIOPSY, RIGID BRONCHOSCOPE                         N     3
                      31626    2                      BRONCHOSCOPY; WITH BIOPSY, FIBEROPTIC BRONCHOSCOPE                    N     3
                      31626    7                      BRONCHOSCOPY; WITH BIOPSY, FIBEROPTIC BRONCHOSCOPE                    N     3
                      31627    2                      BRONCHOSCOPY; WITH BRUSHING, FIBEROPTIC BRONCHOSCO                    N     3
                      31627    7                      BRONCHOSCOPY; WITH BRUSHING, FIBEROPTIC BRONCHOSCO                    N     3
                      31628    2                      BRONCHOSCOPY;W TRANSBRONCHIAL LUNG BIOPSY, FIBEROP                    N     3
                      31628    7                      BRONCHOSCOPY;W TRANSBRONCHIAL LUNG BIOPSY, FIBEROP                    N     3
                      31628    F                      BRONCHOSCOPY;W TRANSBRONCHIAL LUNG BIOPSY, FIBEROP                    N     3
                      31629    2                      BRONCHOSCOPY WITH NEEDLE ASPIRATION                                   N     3
                      31629    7                      BRONCHOSCOPY WITH NEEDLE ASPIRATION                                   N     3
                      31629    F                      BRONCHOSCOPY WITH NEEDLE ASPIRATION                                   N     3
                      31630    2                      BRONCHOSCOPY; WITH TRACHEAL OR BRONCHIAL DILATION                     N     3
                      31630    7                      BRONCHOSCOPY; WITH TRACHEAL OR BRONCHIAL DILATION                     N     3
                      31630    F                      BRONCHOSCOPY; WITH TRACHEAL OR BRONCHIAL DILATION                     N     3
                      31631    7                      BRONCHOSCOPY                                                          N     3
                      31631    F                      BRONCHOSCOPY                                                          N     3
                      31632    2                      BROCHOSCOPY, RIGID OR FLEXIBLE WITH OR WITHOUT FLOUROSCOPIC GUIDA     N     3
                      31633    2                      BRONCHOSCOPY, RIGID OR FLEXIBLE WITH OR WITHOUT FLUOROSCOPIC GUID     N     3
                      31635    2                      BRONCHOSCOPY; WITH REMOVAL OF FOREIGN BODY                            N     3
                      31635    7                      BRONCHOSCOPY; WITH REMOVAL OF FOREIGN BODY                            N     3
                      31635    F                      BRONCHOSCOPY; WITH REMOVAL OF FOREIGN BODY                            N     3
                      31636    2                      BRONCHOSCOPY RIGID OR FLEXIBLE W/WOUT FLUOROSCOPIC                    N     3
                      31636    7                      BRONCHOSCOPY RIGID OR FLEXIBLE W/WITHOUT FLUOROSCOPIC                 N     3
                      31637    2                      BRONSCHOSCOPY RIGID OR FLEXIBLE W/WOUT FLUOROSCOPIC                   N     3
                      31637    7                      BRONCHOSCOPY RIGID OR FLEXIBLE W/WOUT FLUOROSCOPIC                    N     3
                      31638    2                      BRONCHOSCOPY RIGID/FLEXIBLE W/WITHOUT FLUOROSCOPIC                    N     3
                      31638    7                      BRONSCHOSCOPY RIGID/FLEXIBLE W/WITHOUT FLUOROSCOPIC                   N     3
                      31640    2                      BRONCHOSCOPY; WITH EXCISION OF TUMOR                                  N     3
                      31640    7                      BRONCHOSCOPY; WITH EXCISION OF TUMOR                                  N     3
                      31640    F                      BRONCHOSCOPY; WITH EXCISION OF TUMOR                                  N     3
                      31641    2                      BRONCHOSCOPY; W/ DESTRUC OF TUMOR OR REL OF STEN                      N     3
                      31641    F                      BRONCHOSCOPY; W/ DESTRUC OF TUMOR OR REL OF STEN                      N     3




Updated: 09/22/2006                                                                                                                    Page: 131 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      31643    2                      BRONSCHOSCOPY W/PLACEMENT OF CATHERTER FOR INTRACAVITARY              N     3
                      31643    7                      BRONCHOSCOPY W/PLACEMENT OF CATHETER FOR INTRACAVITARY RADIOELEMT     N     3
                      31643    F                      BRONSCHOSCOPY W/PLACEMENT OF CATHERTER FOR INTRACAVITARY              N     3
                      31645    2                      BRONCHOSCOPY; WITH THERAPEUTIC ASPIRATION OF TRACH                    N     3
                      31645    7                      BRONCHOSCOPY; WITH THERAPEUTIC ASPIRATION OF TRACH                    N     3
                      31645    F                      BRONCHOSCOPY; WITH THERAPEUTIC ASPIRATION OF TRACH                    N     3
                      31646    2                      BRONCHOSCOPY; WITH THERAPEUTIC ASPIRATION OF TRACH                    N     3
                      31646    7                      BRONCHOSCOPY; WITH THERAPEUTIC ASPIRATION OF TRACH                    N     3
                      31646    F                      BRONCHOSCOPY; WITH THERAPEUTIC ASPIRATION OF TRACH                    N     3
                      31650    2                      BRONCHOSCOPY; WITH DRAINAGE OF LUNG ABSCESS OR CAV                    N     3
                      31650    7                      BRONCHOSCOPY; WITH DRAINAGE OF LUNG ABSCESS OR CAV                    N     3
                      31651    2                      BRONCHOSCOPY; WITH DRAINAGE OF LUNG ABSCESS OR CAV                    N     3
                      31651    7                      BRONCHOSCOPY; WITH DRAINAGE OF LUNG ABSCESS OR CAV                    N     3
                      31656    7                      BRONCHOSCOPY; WITH INJECTION OF CONTRACT MATERIAL                     N     3
                      31656    F                      BRONCHOSCOPY; WITH INJECTION OF CONTRACT MATERIAL                     N     3
                      31700    2                      CATHETERIZATION, TRANSGLOTTIC                                         N     3
                      31700    7                      CATHETERIZATION, TRANSGLOTTIC                                         N     3
                      31700    F                      CATHETERIZATION, TRANSGLOTTIC                                         N     3
                      31710    2                      CATHETERIZATION FOR BRONCHOGRAPHY, WITH OR WITHOUT                    N     3
                      31717    7                      CATHETERIZATION WITH BRONCHIAL BRUSH BIOPSY                           N     3
                      31717    F                      CATHETERIZATION WITH BRONCHIAL BRUSH BIOPSY                           N     3
                      31720    2                      CATHETER ASPIRATION (SEPARATE PROCEDURE); NASOTRAC                    N     3
                      31720    F                      CATHETER ASPIRATION (SEPARATE PROCEDURE); NASOTRAC                    N     3
                      31730    2                      TRANSTRACHEAL (PERCUTANEOUS) INTRODUCTION OF NEEDL                    N     3
                      31730    7                      TRANSTRACHEAL INTRODUCTIO OF NEEDLE WIRE DILATOR                      N     3
                      31730    F                      TRANSTRACHEAL (PERCUTANEOUS) INTRODUCTION OF NEEDL                    N     3
                      31750    2                      TRACHEOPLASTY; CERVICAL                                               N     3
                      31750    7                      TRACHEOPLASTY; CERVICAL                                               N     3
                      31750    8                      TRACHEOPLASTY; CERVICAL                                               N     3
                      31750    F                      TRACHEOPLASTY; CERVICAL                                               N     3
                      31755    7                      TRACHEOPLASTY; TRACHEOPHARYNGEAL FISTULIZATION, EA                    N     3
                      31755    F                      TRACHEOPLASTY; TRACHEOPHARYNGEAL FISTULIZATION, EA                    N     3
                      31760    2                      TRACHEOPLASTY; INTRATHORACIC                                          N     3
                      31760    7                      TRACHEOPLASTY; INTRATHORACIC                                          N     3
                      31760    8                      TRACHEOPLASTY; INTRATHORACIC                                          N     3
                      31766    7                      CARINAL RECONSTRUCTION                                                N     3
                      31770    7                      BRONCHOPLASTY; GRAFT REPAIR                                           N     3
                      31775    7                      BRONCHOPLASTY; EXCISION STENOSIS AND ANASTOMOSIS                      N     3
                      31780    2                      EXCISION TRACHEAL STENOSIS AND ANASTOMOSIS; CERVIC                    N     3
                      31780    7                      EXCISION TRACHEAL STENOSIS AND ANASTOMOSIS; CERVIC                    N     3
                      31781    2                      EXCISION TRACHEAL STENOSIS AND ANASTOMOSIS; CERVIC                    N     3
                      31781    7                      EXCISION TRACHEAL STENOSIS AND ANASTOMOSIS; CERVIC                    N     3
                      31785    7                      EXCISION OF TRACHEAL TUMOR OR CARCINOMA; CERVICAL                     N     3
                      31786    7                      EXCISION OF TRACHEAL TUMOR OR CARCINOMA; THORACIC                     N     3
                      31800    2                      SUTURE OF EXTERNAL TRACHEAL WOUND OR INJURY; CERVI                    N     3
                      31800    7                      SUTURE OF EXTERNAL TRACHEAL WOUND OR INJURY; CERVI                    N     3
                      31800    8                      SUTURE OF EXTERNAL TRACHEAL WOUND OR INJURY; CERVI                    N     3




Updated: 09/22/2006                                                                                                                    Page: 132 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                  PA IND PAC
                      31805    2                      SUTURE OF EXTERNAL TRACHEAL WOUND OR INJURY; INTRA       N     3
                      31805    7                      SUTURE OF EXTERNAL TRACHEAL WOUND OR INJURY; INTRA       N     3
                      31805    8                      SUTURE OF EXTERNAL TRACHEAL WOUND OR INJURY; INTRA       N     3
                      31820    2                      SURGICAL CLOSURE TRACHEOSTOMY OR FISTULA; WITHOUT        N     3
                      31820    7                      SURGICAL CLOSURE TRACHEOSTOMY OR FISTULA; WITHOUT        N     3
                      31820    F                      SURGICAL CLOSURE TRACHEOSTOMY OR FISTULA; WITHOUT        N     3
                      31825    2                      SURGICAL CLOSURE TRACHEOSTOMY OR FISTULA; WITH PLA       N     3
                      31825    7                      SURGICAL CLOSURE TRACHEOSTOMY OR FISTULA; WITH PLA       N     3
                      31825    F                      SURGICAL CLOSURE TRACHEOSTOMY OR FISTULA; WITH PLA       N     3
                      31830    7                      REVISION OF TRACHEOSTOMY SCAR                            N     3
                      31830    F                      REVISION OF TRACHEOSTOMY SCAR                            N     3
                      31899    7                      UNLISTED PROCEDURE, TRACHEA, BRONCHI                     N     3
                      32000    2                      THORACENTESIS, PUNCTURE OF PLEURAL CAVITY ASPRTN         N     3
                      32000    F                      THORACENTESIS, PUNCTURE OF PLEURAL CAVITY ASPRTN         N     3
                      32002    2                      THORACENTESIS W/INSERT OF TUBE W OR W/O WATER SEAL       N     3
                      32005    2                      CHEMICAL PLEURODESIS (EG, FOR RECURRENT OR PERSIST       N     3
                      32019    2                      INSERTION OF INDWELLING TUNNELED PLEURAL CATH W CUFF     N     3
                      32019    7                      INSERTION OF INDWELLING TUNNELED PLEURAL CATH W CUFF     N     3
                      32020    2                      TUBE THORACOSTOMY WITH WATER SEAL (EG, PNEUMOTHORA       N     3
                      32020    7                      TUBE THORACOSTOMY WITH WATER SEAL                        N     3
                      32020    8                      TUBE THORACOSTOMY WITH WATER SEAL (EG, PNEUMOTHORA       N     3
                      32035    2                      THORACOSTOMY; WITH RIB RESECTION FOR EMPYEMA             N     3
                      32035    7                      THORACOSTOMY; WITH RIB RESECTION FOR EMPYEMA             N     3
                      32035    8                      THORACOSTOMY; WITH RIB RESECTION FOR EMPYEMA             N     3
                      32036    2                      THORACOSTOMY; WITH OPEN FLAP DRAINAGE FOR EMPYEMA        N     3
                      32036    7                      THORACOSTOMY; WITH OPEN FLAP DRAINAGE FOR EMPYEMA        N     3
                      32095    2                      THORACOTOMY LIMITED, FOR BIOPSY OF LUNG OR PLEURA        N     3
                      32095    7                      THORACOTOMY LIMITED, FOR BIOPSY OF LUNG OR PLEURA        N     3
                      32095    8                      THORACOTOMY LIMITED, FOR BIOPSY OF LUNG OR PLEURA        N     3
                      32100    2                      THORACOTOMY, MAJOR; WITH EXPLORATION AND BIOPSY          N     3
                      32100    7                      THORACOTOMY, MAJOR; WITH EXPLORATION AND BIOPSY          N     3
                      32100    8                      THORACOTOMY, MAJOR; WITH EXPLORATION AND BIOPSY          N     3
                      32110    2                      THORACOTOMY, MAJOR; WITH CONTROL OF TRAUMATIC HEMO       N     3
                      32110    7                      THORACOTOMY, MAJOR; WITH CONTROL OF TRAUMATIC HEMO       N     3
                      32110    8                      THORACOTOMY, MAJOR; WITH CONTROL OF TRAUMATIC HEMO       N     3
                      32120    2                      THORACOTOMY, MAJOR; FOR POSTOPERATIVE COMPLICATION       N     3
                      32120    7                      THORACOTOMY, MAJOR; FOR POSTOPERATIVE COMPLICATION       N     3
                      32124    2                      THORACOTOMY, MAJOR; WITH OPEN INTRAPLEURAL PNEUMON       N     3
                      32124    7                      THORACOTOMY, MAJOR; WITH OPEN INTRAPLEURAL PNEUMON       N     3
                      32124    8                      THORACOTOMY, MAJOR; WITH OPEN INTRAPLEURAL PNEUMON       N     3
                      32140    2                      THORACOTOMY, MAJOR; WITH CYST(S) REMOVAL WITH OR W       N     3
                      32140    7                      THORACOTOMY, MAJOR; WITH CYST(S) REMOVAL WITH OR W       N     3
                      32140    8                      THORACOTOMY, MAJOR; WITH CYST(S) REMOVAL WITH OR W       N     3
                      32141    2                      THORACOTOMY, MAJOR; WITH EXCISION-PLICATION OF BUL       N     3
                      32141    7                      THORACOTOMY, MAJOR; WITH EXCISION-PLICATION OF BUL       N     3
                      32141    8                      THORACOTOMY, MAJOR; WITH EXCISION-PLICATION OF BUL       N     3
                      32150    2                      THORACOTOMY, MAJOR; WITH REMOVAL OF INTRAPLEURAL F       N     3




Updated: 09/22/2006                                                                                                       Page: 133 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                           PA IND PAC
                      32150    7                      THORACOTOMY, MAJOR; WITH REMOVAL OF INTRAPLEURAL F                N     3
                      32150    8                      THORACOTOMY, MAJOR; WITH REMOVAL OF INTRAPLEURAL F                N     3
                      32151    2                      THORACOTOMY, MAJOR; WITH REMOVAL OF INTRAPULMONARY                N     3
                      32151    7                      THORACOTOMY, MAJOR; WITH REMOVAL OF INTRAPULMONARY                N     3
                      32151    8                      THORACOTOMY, MAJOR; WITH REMOVAL OF INTRAPULMONARY                N     3
                      32160    7                      THORACOTOMY, MAJOR; WITH CARDIAC MASSAGE                          N     3
                      32200    2                      PNEUMONOSTOMY, WITH OPEN DRAINAGE OF ABSCESS OR CY                N     3
                      32200    7                      PNEUMONOSTOMY, WITH OPEN DRAINAGE OF ABSCESS OR CY                N     3
                      32200    8                      PNEUMONOSTOMY, WITH OPEN DRAINAGE OF ABSCESS OR CY                N     3
                      32201    2                      PNEUMONOSTOMY;W/PERCUTANEOUS DRAINAGE OF ABSCESS OR CYST          N     3
                      32201    7                      PNEUMONOSTOMY;W/PERCUTANEOUS DRAINAGE OF ABSCESS OR CYST          N     3
                      32201    8                      PNEUMONOSTOMY;W/PERCUTANEOUS DRAINAGE OF ABSCESS OR CYST          N     3
                      32215    2                      PLEURAL SCARIFICATION FOR REPEAT PNEUMOTHORAX                     N     3
                      32215    7                      PLEURAL SCARIFICATION FOR REPEAT PNEUMOTHORAX                     N     3
                      32220    2                      DECORTICATION, PULMONARY, (SEPARATE PROCEDURE); TO                N     3
                      32220    7                      DECORTICATION, PULMONARY, (SEPARATE PROCEDURE); TO                N     3
                      32220    8                      DECORTICATION, PULMONARY, (SEPARATE PROCEDURE); TO                N     3
                      32225    2                      DECORTICATION, PULMONARY, (SEPARATE PROCEDURE); PA                N     3
                      32225    7                      DECORTICATION, PULMONARY, (SEPARATE PROCEDURE); PA                N     3
                      32225    8                      DECORTICATION, PULMONARY, (SEPARATE PROCEDURE); PA                N     3
                      32310    2                      PLEURECTOMY; PARIETAL                                             N     3
                      32310    7                      PLEURECTOMY; PARIETAL                                             N     3
                      32310    8                      PLEURECTOMY; PARIETAL                                             N     3
                      32320    7                      DECORTICATION AND PARIETAL PLEURECTOMY                            N     3
                      32400    2                      BIOPSY, PLEURA; PERCUTANEOUS NEEDLE                               N     3
                      32400    7                      BIOPSY, PLEURA; PERCUTANEOUS NEEDLE                               N     3
                      32400    F                      BIOPSY, PLEURA; PERCUTANEOUS NEEDLE                               N     3
                      32402    2                      BIOPSY, PLEURA; OPEN                                              N     3
                      32402    7                      BIOPSY, PLEURA; OPEN                                              N     3
                      32402    8                      BIOPSY, PLEURA; OPEN                                              N     3
                      32405    2                      BIOPSY, LUNG, PERCUTANEOUS NEEDLE                                 N     3
                      32405    7                      BIOPSY, LUNG, PERCUTANEOUS NEEDLE                                 N     3
                      32405    F                      BIOPSY, LUNG, PERCUTANEOUS NEEDLE                                 N     3
                      32420    2                      PNEUMONOCENTESIS, PUNCTURE OF LUNG FOR ASPIRATION                 N     3
                      32420    7                      PNEUMONOCENTESIS, PUNCTURE OF LUNG FOR ASPIRATION                 N     3
                      32420    F                      PNEUMONOCENTESIS, PUNCTURE OF LUNG FOR ASPIRATION                 N     3
                      32440    2                      PNEUMONECTOMY, TOTAL                                              N     3
                      32440    7                      PNEUMONECTOMY, TOTAL                                              N     3
                      32440    8                      PNEUMONECTOMY, TOTAL                                              N     3
                      32442    2                      REMOVAL OF LUNG, TOTAL PNEUMONECTOMY;                             N     3
                      32445    7                      PNEUMONECTOMY, EXTRAPLEURAL; WITHOUT EMPYEMECTOMY                 N     3
                      32480    2                      LOBECTOMY, TOTAL OR SEGMENTAL;                                    N     3
                      32480    7                      LOBECTOMY, TOTAL OR SEGMENTAL;                                    N     3
                      32480    8                      LOBECTOMY, TOTAL OR SEGMENTAL;                                    N     3
                      32482    2                      REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY;                  N     3
                      32482    7                      ANESTHESIA, REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY       N     3
                      32482    8                      ASSISTANT FEE REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY     N     3




Updated: 09/22/2006                                                                                                                Page: 134 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      32484    2                      REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY;                      N     3
                      32484    7                      ANESTHESIA;REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY            N     3
                      32484    8                      ASSISTANT FEE;REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY         N     3
                      32485    7                      LOBECTOMY, TOTAL OR SEGMENTAL; WITH BRONCHOPLASTY                     N     3
                      32486    2                      REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY;                      N     3
                      32488    2                      REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY;                      N     3
                      32500    2                      WEDGE RESECTION OF LUNG, SINGLE OR MULTIPLE                           N     3
                      32500    7                      WEDGE RESECTION OF LUNG, SINGLE OR MULTIPLE                           N     3
                      32500    8                      WEDGE RESECTION OF LUNG, SINGLE OR MULTIPLE                           N     3
                      32501    2                      RESECTION/REPAIR OF BRONCHUS AT TIME OF LOBE/SEGMENTECTOMY            N     3
                      32501    8                      RESECTION/REPAIR OF BRONCHUS AT TIME OF LOBE/SEGMENTECTOMY            N     3
                      32503    2                      RESECTION OF APICAL LUNG TUMOR (EG, PANCOAST TUMOR), INCLUDING CH     N     3
                      32503    7                      RESECTION OF APICAL LUNG TUMOR (EG, PANCOAST TUMOR), INCLUDING CH     N     3
                      32503    8                      RESECTION OF APICAL LUNG TUMOR (EG, PANCOAST TUMOR), INCLUDING CH     N     3
                      32504    2                      RESECTION OF APICAL LUNG TUMOR (EG, PANCOAST TUMOR), INCLUDING CH     N     3
                      32504    7                      RESECTION OF APICAL LUNG TUMOR (EG, PANCOAST TUMOR), INCLUDING CH     N     3
                      32504    8                      RESECTION OF APICAL LUNG TUMOR (EG, PANCOAST TUMOR), INCLUDING CH     N     3
                      32540    2                      EXTRAPLEURAL ENUCLEATION OF EMPYEMA (EMPYEMECTOMY)                    N     3
                      32540    7                      EXTRAPLEURAL ENUCLEATION OF EMPYEMA (EMPYEMECTOMY)                    N     3
                      32540    8                      EXTRAPLEURAL ENUCLEATION OF EMPYEMA (EMPYEMECTOMY)                    N     3
                      32601    2                      THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE);                        N     3
                      32601    7                      THORACOSCOPY, DIAGNOSTIC - ANESTHESIA                                 N     3
                      32602    2                      THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE);                        N     3
                      32602    7                      ANESTHESIA FOR THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)          N     3
                      32602    8                      THORACOSCOPY, DIAGNOSTIC -ASSISTANT SURGEON                           N     3
                      32603    2                      THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE);                        N     3
                      32604    2                      THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE);                        N     3
                      32605    2                      THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE);                        N     3
                      32606    2                      THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE);                        N     3
                      32650    2                      THORACOSCOPY, SURGICAL;                                               N     3
                      32651    2                      THORACOSCOPY, SURGICAL;                                               N     3
                      32652    2                      THORACOSCOPY, SURGICAL;                                               N     3
                      32653    2                      THORACOSCOPY, SURGICAL;                                               N     3
                      32654    2                      THORACOSCOPY, SURGICAL;                                               N     3
                      32655    2                      THORACOSCOPY, SURGICAL;                                               N     3
                      32655    7                      ANESTHESIA FOR THORACOSCOPY, SURGICAL                                 N     3
                      32656    2                      THORACOSCOPY, SURGICAL;                                               N     3
                      32657    2                      THORACOSCOPY, SURGICAL;                                               N     3
                      32658    2                      THORACOSCOPY, SURGICAL;                                               N     3
                      32659    2                      THORACOSCOPY, SURGICAL;                                               N     3
                      32659    7                      THOROSCOPY WITH CREATION OF PERICARDIAL WINDOW OR PARTIAL RESECTI     N     3
                      32660    2                      THORACOSCOPY, SURGICAL;                                               N     3
                      32661    2                      THORACOSCOPY, SURGICAL;                                               N     3
                      32662    2                      THORACOSCOPY, SURGICAL;                                               N     3
                      32663    2                      THORACOSCOPY, SURGICAL;                                               N     3
                      32664    2                      THORACOSCOPY, SURGICAL;                                               N     3
                      32665    2                      THORACOSCOPY, SURGICAL;                                               N     3




Updated: 09/22/2006                                                                                                                    Page: 135 of 435
                               NH MEDICAID FEE SCHEDULE - COVERED PROCEDURES (THAT ARE NOT MANUALLY PRICED)

                      PROC    TOS MOD1 MOD2 MOD3 MOD4 PROCEDURE DESCRIPTION                                               PA IND PAC
                      32800    7                      REPAIR LUNG HERNIA THROUGH CHEST WALL                                 N     3
                      32800    8                      REPAIR LUNG HERNIA THROUGH CHEST WALL                                 N     3
                      32810    2                      CLOSURE OF CHEST WALL                                                 N     3
                      32810    7                      CLOSURE OF CHEST WALL FOLLOWING OPEN FLAP DRAINAGE                    N     3
                      32815    7                      OPEN CLOSURE OF MAJOR BRONCHIAL FISTULA                               N     3
                      32820    2                      MAJOR RECONSTRUCTION, CHEST WALL (POST-TRAUMATIC)                     N     3
                      32820    7                      MAJOR RECONSTRUCTION, CHEST WALL (POST-TRAUMATIC)                     N     3
                      32820    8                      MAJOR RECONSTRUCTION, CHEST WALL (POST-TRAUMATIC)                     N     3
                      32900    2                      RESECTION OF RIBS, EXTRAPLEURAL, ALL STAGES                           N     3
                      32900    7                      RESECTION OF RIBS, EXTRAPLEURAL, ALL STAGES                           N     3
                      32900    8                      RESECTION OF RIBS, EXTRAPLEURAL, ALL STAGES                           N     3
                      32905    2                      THORACOPLASTY, SCHEDE TYPE OR EXTRAPLEURAL (ALL ST                    N     3
                      32905    7                      THORACOPLASTY, SCHEDE TYPE OR EXTRAPLEURAL (ALL ST                    N     3
                      32905    8                      THORACOPLASTY, SCHEDE TYPE OR EXTRAPLEURAL (ALL ST                    N     3
                      32906    7                      THORACOPLASTY, SCHEDE TYPE OR EXTRAPLEURAL; WITH C                    N     3
                      32940    2                      PNEUMONOLYSIS, EXTRAPERIOSTEAL, INCLUDING FILLING                     N     3
                      32940    7                      PNEUMONOLYSIS, EXTRAPERIOSTEAL, INCLUDING FILLING                     N     3
                      32940    8                      PNEUMONOLYSIS, EXTRAPERIOSTEAL, INCLUDING FILLING                     N     3
                      32960    2                      PNEUMOTHORAX, THERAPEUTIC, INTRAPLEURAL INJECTION                     N     3
                      32997    2                      TOTAL LUNG LAVAGE (UNILATERAL)                                        N     3
                      32999    7                      UNLISTED PROCEDURE, LUNGS AND PLEURA                                  N     3
                      33010    2                      PERICARDIOCENTESIS; INITIAL                                           N     3
                      33010    7                      PERICARDIOCENTESIS INITIAL                                            N     3
                      33010    F                      PERICARDIOCENTESIS; INITIAL                                           N     3
                      33011    2                      PERICARDIOCENTESIS; SUBSEQUENT                                        N     3
                      33011    7                      PERFCARDIOCENTESIS; SUBSEQUENT                                        N     3
                      33011    F                      PERICARDIOCENTESIS; SUBSEQUENT                                        N     3
                      33015    2                      TUBE PERICARDIOSTOMY                                                  N     3
                      33015    7                      TUBE