MCP Fee Schedule by MikeJenny

VIEWS: 1,243 PAGES: 356

									                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
0001F         Hrt Failure Assessed                                               $0.00
0001T         Endovsc Rpr Abdm Aort Anyrsm, Prsth                                $0.00
00020         Medical Equipment (E.G.,Inflatable Braces, Wheelch                 $0.00
0002F         Assessment, Tobacco Use, Smoking                                   $0.00
0002T         Endovsc Rpr Abdm Ao Anyrsm                                         $0.00
00030         Mileage-Less Than 100 Miles-Per Mile                               $6.45
00031         Mileage-More Than 99 Miles                                         $6.45
0003F         Assmnt, Tobacco Use, Non-Smoking                                   $0.00
0003T         Cervicography                                                      $0.00
0004F         Counsel, Stop Tobacco Use, Intrvn                                  $0.00
0005F         Osteoarthritis Assessed                                            $0.00
0005T         Crbrlvsc Art Stent, Percu, Initial                                 $0.00
0006F         Statin Therapy, Prescribed                                         $0.00
0006T         Crbrlvsc Art Stent, Percu, Ea Add                                  $0.00
0007F         Beta-Blocker Therapy, Prescribed                                   $0.00
0007T         Crbrlvsc Art Stent, Percu, Rad S&I                                 $0.00
0008F         Ace Inhibitor Therapy, Prescribed                                  $0.00
0008T         Upper Gastrointestinal Endoscopy Including Esophagus, Stomac       $0.00
00090         Ihs Ambulatory Surgery Center I                                 $330.94
00091         Ihs Ambulatory Surgery Center Ii                                $443.23
00092         Ihs Ambulatory Surgery Center Iii                               $506.84
00093         Ihs Ambulatory Surgery Center Iv                                $626.09
00094         Ihs Ambulatory Surgery Center V                                 $712.55
00095         Ihs Ambulatory Surgery Center Vi                                $821.81
00096         Ihs Ambulatory Surgery Center Vii                               $988.83
00097         Ihs Ambulatory Surgery Center Viii                              $967.90
00098         Ihs Ambulatory Surgery Center Ix                               $1,094.69
00099         Ihs-Outpatient Reimbursement Rate                               $206.00
0009F         Assmnt, Anginal Symp/Activity Level                                $0.00
0009T         Cryoabltn Endomtrl W/Ultrsnd Guide                                 $0.00
09950         Bilateral Procedure                                               $54.49
09951         Multiple Procedures                                               $21.37
09952         Reduced Services                                                  $87.00
09999         Multiple Modifiers                                                 $0.00
10001         Incision And Drainage Of Infected Or Noninfected Sebaceous        $15.00
10002         Incision And Drainage Of Infected Or Noninfected Sebaceous         $1.40
10003         Incision And Drainage Of Infected Or Noninfected Epithelial       $41.00
10020         Incision And Drainage Of Furuncle                                 $30.25
10021         Fine Ndl Aspir W/O Img Gdn                                      $131.01
10021   26    Fine Ndl Aspir W/O Img Gdn                                        $39.30
10021   TC    Fine Ndl Aspir W/O Img Gdn                                        $91.71
10022         Fine Ndl Aspir W/Img Gdn                                        $145.17
10022   26    Fine Ndl Aspir W/Img Gdn                                          $43.55
10022   TC    Fine Ndl Aspir W/Img Gdn                                        $101.62
10040         Acne Surg                                                         $83.75
10060         I&D Absc Smpl/1                                                   $91.57
10061         I&D Absc Comp/Mlt                                               $164.25
10080         I&D Pilonidal Cst Smpl                                          $162.46
10081         I&D Pilonidal Cst Comp                                          $250.92
10100         Incision And Drainage Of Onychia Or Paronychia                    $27.80
10101         Incision And Drainage Of Onychia Or Paronychia                    $29.80
10120         Inc&Rmvl Fb Subq Tiss Smpl                                      $103.75
10121         Inc&Rmvl Fb Subq Tiss Comp                                      $234.25
10140         I&D Hmtma Seroma/Flu Collj                                      $119.59
10141         Incision And Drainage Of Hematoma; Complicated                  $115.23

                                            Page 1
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                  Amount
10160         Pnxr Aspir Absc Hmtma Bulla/Cst                               $76.75
10180         I&D Cplx Po Wnd Infctj                                       $214.90
11000         Dbrdmt X10Sv Eczmt/Infct Skn Up 10% Bdy Surf                  $45.66
11001         Dbrdmt X10Sv Eczmt/Infct Skn Ea 10% Bdy Surf                  $20.41
11004         Dbrdmt Skn Subq T/M/F Necro Infctj Gent&Pr                   $563.45
11005         Dbrdmt Skn Subq T/M/F Necro Infctj Abdl Wal                  $767.53
11006         Dbrdmt Skn Subq T/M/F Necro Infctj Gent/Abdl                 $710.79
11008         Rmvl Prostc Matrl/Mesh Abdl Wall Necro Tiss                  $289.60
11010         Dbrdmt W/Rmvl Fm Fx&/Dislc Skn&Subq Tiss                     $424.54
11011         Dbrdmt W/Rmvl Fm Fx&/Dislc Skn Subq T/M/F Musc               $503.72
11012         Dbrdmt W/Rmvl Fm Fx&/Dislc Skn Subq T/M/F Musc               $738.61
11040         Dbrdmt Skn Prtl Thkns                                         $39.73
11041         Dbrdmt Skn Full Thkns                                         $57.20
11042         Removal Of Damaged Skin And Underlying Tissue                 $81.72
11043         Dbrdmt Skn Subq Tiss&Musc                                    $225.18
11044         Dbrdmt Skn Subq Tiss Musc&B1                                 $295.26
11052         Paring Or Curettement Of Benign Hyperkeratotic Skin Lesion    $45.16
11055         Paring/Cutting B9 Hyprkeratotic Les 1 Les                     $36.95
11056         Paring/Cutting B9 Hyprkeratotic Les 2-4                       $47.41
11057         Paring/Cutting B9 Hyprkeratotic Les >4                        $58.19
11060         Shaving Of Epidermal Or Superficial Dermal Lesion             $22.08
11061         Shaving Of Epidermal Or Superficial Dermal Lesion             $35.19
11062         Shaving Of Epidermal Or Superficial Dermal Lesion             $51.06
11100         Bx Skn Subq/Muc Memb 1 Lesion                                 $78.29
11101         Bx Skn Subq/Muc Memb Ea Spx Addl Lesion                       $28.54
11200         Rmvl Sk Tgs Mlt Fibrq Tags Any Area Up&W/15 <                 $69.49
11201         Rmvl Sk Tgs Mlt Fibrq Tags Any Area Ea 10 <                   $17.48
11300         Shvg Skn Les 1 Les T/A/L Diam 0.5 Cm/<                        $57.19
11301         Shvg Skn Les 1 Les T/A/L Diam 0.6-1.0 Cm                      $74.67
11302         Shvg Skn Les 1 Les T/A/L Diam 1.1-2.0 Cm                      $89.48
11303         Shvg Skn Les 1 Les T/A/L Diam > 2.0 Cm                       $107.21
11305         Shvg Skn Les 1 Les S/N/H/F/G Diam 0.5 Cm/<                    $57.72
11306         Shvg Skn Les 1 Les S/N/H/F/G Diam 0.6-1.0 Cm                  $79.94
11307         Shvg Skn Les 1 Les S/N/H/F/G Diam 1.1-2.0 Cm                  $92.11
11308         Shvg Skn Les 1 Les S/N/H/F/G Diam > 2.0 Cm                   $108.85
11310         Shvg Skn Les 1 Les F/E/E/N/L/M Diam 0.5 Cm/<                  $70.19
11311         Shvg Skn Les 1 Les F/E/E/N/L/M Diam 0.6-1.0 Cm                $86.93
11312         Shvg Skn Les 1 Les F/E/E/N/L/M Diam 1.1-2.0 Cm               $100.24
11313         Shvg Skn Les 1 Les F/E/E/N/L/M Les Diam > 2.0 Cm             $131.42
11400         Exc B9 Les Mrgn Xcp Sk Tg T/A/L 0.5 Cm/<                     $107.62
11401         Exc B9 Les Mrgn Xcp Sk Tg T/A/L 0.6-1.0 Cm                   $125.99
11402         Exc B9 Les Mrgn Xcp Sk Tg T/A/L 1.1-2.0 Cm                   $144.24
11403         Exc B9 Les Mrgn Xcp Sk Tg T/A/L 2.1-3.0 Cm                   $162.94
11404         Exc B9 Les Mrgn Xcp Sk Tg T/A/L 3.1-4.0 Cm                   $185.56
11406         Exc B9 Les Mrgn Xcp Sk Tg T/A/L > 4.0 Cm                     $228.46
11420         Exc B9 Les Mrgn Xcp Sk Tg S/N/H/F/G 0.5 Cm/<                 $105.29
11421         Exc B9 Les Mrgn Xcp Sk Tg S/N/H/F/G 0.6-1.0Cm                $134.26
11422         Exc B9 Les Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0Cm                $150.67
11423         Exc B9 Les Mrgn Xcp Sk Tg S/N/H/F/G 2.1-3.0Cm                $178.90
11424         Exc B9 Les Mrgn Xcp Sk Tg S/N/H/F/G 3.1-4.0Cm                $203.88
11426         Exc B9 Les Mrgn Xcp Sk Tg S/N/H/F/G > 4.0Cm                  $285.98
11440         Exc B9 Les Mrgn Xcp Sk Tg F/E/E/N/L/M 0.5Cm/<                $126.90
11441         Exc B9 Les Mrgn Xcp Sk Tg F/E/E/N/L/M 0.6-1.0Cm              $148.19
11442         Exc B9 Les Mrgn Xcp Sk Tg F/E/E/N/L/M 1.1-2.0Cm              $165.72
11443         Exc B9 Les Mrgn Xcp Sk Tg F/E/E/N/L/M 2.1-3.0Cm              $202.91

                                             Page 2
                           MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
11444         Exc B9 Les Mrgn Xcp Sk Tg F/E/E/N/L/M 3.1-4.0Cm                $258.72
11446         Exc B9 Les Mrgn Xcp Sk Tg F/E/E/N/L/M > 4.0Cm                  $332.00
11450         Exc Skn&Subq Hidradnt Ax W/Smpl/Intrm Rpr                      $301.14
11451         Exc Skn&Subq Hidradnt Ax W/Cplx Rpr                            $412.35
11462         Exc Skn&Subq Hidradnt Ingun W/Smpl/Intrm Rpr                   $295.00
11463         Exc Skn&Subq Hidradnt Ingun W/Cplx Rpr                         $420.80
11470         Exc Skn&Subq H/P/Pu Smpl/Intrm Rpr                             $323.69
11471         Exc Skn&Subq H/P/P/U Cplx Rpr                                  $433.95
11600         Exc Mal Les W/Mrgn T/A/L 0.5 Cm/<                              $150.16
11601         Exc Mal Les W/Mrgn T/A/L 0.6-1.0 Cm                            $172.23
11602         Exc Mal Les W/Mrgn T/A/L 1.1-2.0 Cm                            $183.76
11603         Exc Mal Les W/Mrgn T/A/L 2.1-3.0 Cm                            $203.07
11604         Exc Mal Les W/Mrgn T/A/L 3.1-4.0 Cm                            $223.08
11606         Exc Mal Les W/Mrgn T/A/L > 4.0 Cm                              $291.61
11620         Exc Mal Les W/Mrgn S/N/H/F/G 0.5 Cm/<                          $144.58
11621         Exc Mal Les W/Mrgn S/N/H/F/G 0.6-1.0 Cm                        $171.10
11622         Exc Mal Les W/Mrgn S/N/H/F/G 1.1-2.0 Cm                        $194.91
11623         Exc Mal Les W/Mrgn S/N/H/F/G 2.1-3.0 Cm                        $229.91
11624         Exc Mal Les W/Mrgn S/N/H/F/G 3.1-4.0 Cm                        $264.86
11626         Exc Mal Les W/Mrgn S/N/H/F/G > 4.0 Cm                          $348.90
11640         Exc Mal Les W/Mrgn F/E/E/N/L/M 0.5 Cm/<                        $153.52
11641         Exc Mal Les W/Mrgn F/E/E/N/L/M 0.6-1.0 Cm                      $199.71
11642         Exc Mal Les W/Mrgn F/E/E/N/L/M 1.1-2.0 Cm                      $231.27
11643         Exc Mal Les W/Mrgn F/E/E/N/L/M 2.1-3.0 Cm                      $268.13
11644         Exc Mal Les W/Mrgn F/E/E/N/L/M 3.1-4.0 Cm                      $339.46
11646         Exc Mal Les W/Mrgn F/E/E/N/L/M > 4.0 Cm                        $456.33
11700         Debridement Of Nails, Manual; Five Or Less                      $27.62
11701         Debridement Of Nails, Manual; Each Additional, Five Or Less     $19.79
11710         Debridement Of Nails, Electric Grinder; Five Or Less            $27.62
11711         Debridement Of Nails, Electric Grinder; Each Additional, Fiv    $16.90
11719         Trimming Nondystrophic Nails Any Number                         $15.88
11720         Dbrdmt Nail Any Meth 1-5                                        $25.18
11721         Dbrdmt Nail Any Meth 6/>                                        $37.90
11730         Avlsn Nail Plate Prtl/Compl Smpl 1                              $83.91
11731         Avulsion Of Nail Plate, Simple; Second Nail Plate               $39.90
11732         Avlsn Nail Plate Prtl/Compl Smpl Ea Nail Plate                  $39.43
11740         Evac Subungual Hmtma                                            $46.48
11750         Exc Nail Matrix Prm Rmvl                                       $154.96
11752         Exc Nail Matrix Prm Rmvl W/Amp Tuft Dstl Phalanx               $223.69
11755         Bx Nail Unit Spx                                                $91.93
11760         Rpr Nail Bed                                                   $134.73
11762         Rcnstj Nail Bed W/Grf                                          $206.67
11765         Wedge Exc Skn Nail Fold                                         $69.83
11770         Exc Pilonidal Cst/Sinus Smpl                                   $237.79
11771         Exc Pilonidal Cst/Sinus X10Sv                                  $449.76
11772         Exc Pilonidal Cst/Sinus Comp                                   $555.43
11900         Njx Ilesn Up&W/7 <                                              $43.96
11901         Njx Ilesn > 7                                                   $55.60
11920         Tattooing Correct Color Dfcts 6.0 Cm/<                         $141.33
11921         Tattooing Correct Color Dfcts 6.1-20.0 Cm                      $168.41
11922         Tattooing Correct Color Dfcts Ea 20.0 Cm                        $34.25
11950         Subq Njx Filling Matrl 1 Cc/<                                   $76.21
11951         Subq Njx Filling Matrl 1.1-5.0 Cc                              $104.09
11952         Subq Njx Filling Matrl 5.1-10.0 Cc                             $139.93
11954         Subq Njx Filling Matrl > 10.0 Cc                               $167.53

                                              Page 3
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                      Amount
11960         Insj Tiss Expander Oth/Thn Brst Sbsq Xpnsj       $765.94
11970         Rplcmt Tiss Expander Prm Prosth                  $523.83
11971         Rmvl Tiss Expander W/O Insj Prosth               $348.97
11975         Insj Impltable Contraceptive Capsls              $114.03
11976         Rmvl Impltable Contraceptive Capsls              $137.08
11977         Rmvl W/Rinsj Impltable Contraceptive Capsls      $221.16
11980         Subq Horm Pellet Impltj                          $100.31
11981         Insj Non-Biodegradable Drug Dlvr Implt           $125.72
11982         Rmvl Non-Biodegradable Drug Dlvr Implt           $146.94
11983         Rmvl W/Rinsj Non-Biodegradable Drug Dlvr Implt   $222.99
12001         Smpl Rpr Supfc S/N/Ax/G/T 2.5Cm/<                $143.02
12002         Smpl Rpr Supfc S/N/Ax/G/T 2.6Cm-7.5Cm            $152.00
12004         Smpl Rpr Supfc S/N/Ax/G/T 7.6Cm-12.5Cm           $178.36
12005         Smpl Rpr Supfc S/N/Ax/G/T 12.6Cm-20.0Cm          $222.25
12006         Smpl Rpr Supfc S/N/Ax/G/T 20.1Cm-30.0Cm          $276.96
12007         Smpl Rpr Supfc S/N/Ax/G/T > 30.0Cm               $312.72
12011         Smpl Rpr Supfc F/E/E/N/L/M 2.5Cm/<               $151.51
12013         Smpl Rpr Supfc F/E/E/N/L/M 2.6Cm-5.0Cm           $166.39
12014         Smpl Rpr Supfc F/E/E/N/L/M 5.1Cm-7.5Cm           $196.11
12015         Smpl Rpr Supfc F/E/E/N/L/M 7.6Cm-12.5Cm          $247.39
12016         Smpl Rpr Supfc F/E/E/N/L/M 12.6Cm-20.0Cm         $293.69
12017         Smpl Rpr Supfc F/E/E/N/L/M 20.1Cm-30. Cm         $264.36
12018         Smpl Rpr Supfc F/E/E/N/L/M > 30.0Cm              $311.38
12020         Tx Supfc Dehsn Smpl Clsr                         $206.39
12021         Tx Supfc Dehsn W/Packing                         $141.60
12031         Lyr Clsr S/A/T/E 2.5 Cm/<                        $171.95
12032         Lyr Clsr S/A/T/E 2.6 Cm-7.5 Cm                   $241.23
12034         Lyr Clsr S/A/T/E 7.6 Cm-12.5 Cm                  $234.96
12035         Lyr Clsr S/A/T/E 12.6 Cm-20.0 Cm                 $334.42
12036         Lyr Clsr S/A/T/E 20.1 Cm-30.0 Cm                 $366.51
12037         Lyr Clsr S/A/T/E > 30.0 Cm                       $432.07
12041         Lyr Clsr N/H/F/Xtrnl Gent 2.5 Cm/<               $187.23
12042         Lyr Clsr N/H/F/Xtrnl Gent 2.6 Cm-7.5 Cm          $228.07
12044         Lyr Clsr N/H/F/Xtrnl Gent 7.6 Cm-12.5 Cm         $245.89
12045         Lyr Clsr N/H/F/Xtrnl Gent 12.6 Cm-20.0 Cm        $286.23
12046         Lyr Clsr N/H/F/Xtrnl Gent 20.1 Cm-30.0 Cm        $417.76
12047         Lyr Clsr N/H/F/Xtrnl Gent > 30.0 Cm              $427.62
12051         Lyr Clsr F/E/E/N/L/M&/Muc 2.5 Cm/<               $217.90
12052         Lyr Clsr F/E/E/N/L/M&/Muc 2.6 Cm-5.0 Cm          $227.73
12053         Lyr Clsr F/E/E/N/L/M&/Muc 5.1 Cm-7.5 Cm          $243.84
12054         Lyr Clsr F/E/E/N/L/M&/Muc 7.6 Cm-12.5 Cm         $270.29
12055         Lyr Clsr F/E/E/N/L/M&/Muc 12.6 Cm-20.0 Cm        $347.91
12056         Lyr Clsr F/E/E/N/L/M&/Muc 20.1 Cm-30.0 Cm        $463.29
12057         Lyr Clsr F/E/E/N/L/M&/Muc > 30.0 Cm              $469.32
13100         Rpr Cplx Trnk 1.1 Cm-2.5 Cm                      $254.84
13101         Rpr Cplx Trnk 2.6 Cm-7.5 Cm                      $293.91
13102         Rpr Cplx Trnk Ea 5 Cm/<                           $78.20
13120         Rpr Cplx S/A/L 1.1 Cm-2.5 Cm                     $266.43
13121         Rpr Cplx S/A/L 2.6 Cm-7.5 Cm                     $318.48
13122         Rpr Cplx S/A/L Ea 5 Cm/<                          $91.23
13131         Rpr Cplx F/C/C/M/N/Ax/G/H/F 1.1 Cm-2.5 Cm        $295.03
13132         Rpr Cplx F/C/C/M/N/Ax/G/H/F 2.6 Cm-7.5 Cm        $408.55
13133         Rpr Cplx F/C/C/M/N/Ax/G/H/F Ea 5 Cm/<            $133.77
13150         Rpr Cplx E/N/E/L 1.0 Cm/<                        $356.96
13151         Rpr Cplx E/N/E/L 1.1 Cm-2.5 Cm                   $376.80

                                            Page 4
                           MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
13152         Rpr Cplx E/N/E/L 2.6 Cm-7.5 Cm                                 $476.71
13153         Rpr Cplx E/N/E/L Ea 5 Cm/<                                     $146.75
13160         Sec Clsr Surg Wnd/Dehsn X10Sv/Comp                             $709.88
13300         Repair, Unusual, Complicated, Over 7.5 Cm, Any Area            $399.07
14000         Att/Reargmt Trnk Dfct 10 Cm/<                                  $553.04
14001         Att/Reargmt Trnk Dfct 10.1 Cm-30.0 Cm                          $710.59
14020         Att/Reargmt S/A/L Dfct 10 Cm/<                                 $604.95
14021         Att/Reargmt S/A/L Dfct 10.1 Cm-30.0 Cm                         $790.24
14040         Att/Reargmt F/C/C/M/N/Ax/G/H/F 10 Cm/<                         $621.59
14041         Att/Reargmt F/C/C/M/N/Ax/G/H/F 10.1Cm-30.0Cm                   $851.79
14060         Att/Reargmt E/N/E/L Dfct 10 Cm/<                               $677.46
14061         Att/Reargmt E/N/E/L Dfct 10.1 Cm-30.0 Cm                       $920.53
14300         Att/Reargmt > 30 Cm Unusual/Comp Any Area                      $890.09
14350         Filleted Fngr/Toe Flap W/Prepj Rcp Sit                         $671.75
15000         Surgical Preparation Or Creation Of Recipient Site By Excisi   $306.42
15001         Surgical Preparation Or Creation Of Recipient Site By Excisi    $92.29
15040         Harvest Skn Tiss Cltr Skn Agrft 100 Cm/<                       $257.32
15050         Pinch Grf 1/Mlt C> Sm Ulcer Tip/Oth Area 2Cm                   $400.56
15100         Splt Agrft T/A/L 1St 100 Cm/</1% Bdy Inft/Chld                 $844.72
15101         Splt Agrft T/A/L Ea 100 Cm/Ea 1% Bdy Inft/Chld                 $213.03
15110         Epidrm Agrft T/A/L 1St 100 Cm/</1% Bdy Inft/Chld               $815.36
15111         Epidrm Agrft T/A/L Ea 100 Cm/Ea 1% Bdy Inft/Chld               $129.14
15115         Epidrm Agrft F/S/N/H/F/G/M/D Gt 1St 100 Cm                     $766.11
15116         Epidrm Agrft F/S/N/H/F/G/M/D Gt Ea 100 Cm/Ea                   $167.51
15120         Splt Agrft F/S/N/H/F/G/M/D Gt 1St 100 Cm/</1%                  $804.66
15121         Splt Agrft F/S/N/H/F/G/M/D Gt Ea 100 Cm/Ea 1 %                 $280.36
15130         Drm Agrft T/A/L 1St 100 Cm                                     $676.39
15131         Drm Agrft T/A/L Ea 100 Cm/Ea                                   $105.58
15135         Drm Agrft F/S/N/H/F/G/M/D Gt 1St 100                           $819.94
15136         Drm Agrft F/S/N/H/F/G/M/D Gt Ea 100 Cm/Ea                       $98.41
15150         Cltr Epidrm Agrft T/A/L 1St 25 Cm/<                            $677.64
15151         Cltr Epidrm Agrft T/A/L Addl 1 Cm-75 Cm                        $136.39
15152         Cltr Epidrm Agrft T/A/L Ea 100 Cm/Ea 1 % Bdy                   $167.57
15155         Cltr Epidrm Agrft F/S/N/H/F/G/M/D Gt 1St 25Cm/<                $678.36
15156         Cltr Epidrm Agrft F/S/N/H/F/G/M/D Gt Addl 1-75Cm               $177.45
15157         Cltr Epidrm Agrft F/S/N/H/F/G/M/D Gt Ea 100 Ea                 $196.41
15170         Aclr Drm Rplcmt T/A/L 1St 100 Cm/</1 % Bdy                     $356.13
15171         Aclr Drm Rplcmt T/A/L Ea 100 Cm/Ea 1 % Bdy                      $92.00
15175         Aclr Drm Rplcmt F/S/N/H/F/G/M/D Gt 1St 100 Cm                  $503.02
15176         Aclr Drm Rplcmt F/S/N/H/F/G/M/D Gt Ea 100 Cm/Ea                $146.33
15200         Fth/Gft Fr W/Dir Clsr Trnk 20 Cm/<                             $726.35
15201         Fth/Gft Fr W/Dir Clsr Trnk Ea 20 Cm                             $94.18
15220         Fth/Gft Fr W/Dir Clsr S/A/L 20 Cm/<                            $713.55
15221         Fth/Gft Fr W/Dir Clsr S/A/L Ea 20 Cm                            $83.36
15240         Fth/Gft Fr W/Dir Clsr F/C/C/M/N/Ax/G/H/F 20 Cm/<               $746.86
15241         Fth/Gft Fr W/Dir Clsr F/C/C/M/N/Ax/G/H/F Ea 20Cm               $130.94
15260         Fth/Gft Fr W/Dir Clsr N/E/E/L 20 Cm/<                          $766.58
15261         Fth/Gft Fr W/Dir Clsr N/E/E/L Ea 20 Cm                         $191.13
15300         Algrft Skn F/Temp Clsr T/A/L 1St 100 Cm/</1                    $291.74
15301         Algrft Skn F/Temp Clsr T/A/L Ea 100 Cm/Ea                       $61.24
15320         Algrft Skn F/Temp Clsr F/S/N/H/F/G/M/D 1St 100Cm               $338.08
15321         Algrft Skn F/Temp Clsr F/S/N/H/F/G/M/D Ea 100Cm                 $91.29
15330         Aclr Drm Algrft T/A/L 1St 100 Cm                               $291.36
15331         Aclr Drm Algrft T/A/L Ea 100 Cm/Ea                              $60.86
15335         Aclr Drm Algrft F/S/N/H/F/G/M/D Gt 1St 100 Cm                  $323.65

                                               Page 5
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
15336         Aclr Drm Algrft F/S/N/H/F/G/M/D Gt Ea 100 Cm/Ea                   $88.24
15340         Tiss Cltr Algc Skn 1St 25 Cm/<                                  $308.34
15341         Tiss Cltr Algc Skn Ea 25 Cm                                       $44.31
15342         Application Of Bilaminate Skin Substitute/Neodermis; 25 Sq C    $108.64
15343         Application Of Bilaminate Skin Substitute/Neodermis; Each Ad      $20.01
15350         Application Of Allograft, Skin; 100 Sq Cm Or Less               $469.89
15351         Application Of Allograft, Skin; Each Additional 100 Sq Cm (L      $76.95
15360         Tiss Cltr Algc Drm T/A/L 1St 100 Cm                              $332.51
15361         Tiss Cltr Algc Drm Ea 100 Cm/Ea                                   $71.06
15365         Tiss Cltr Algc Drm F/S/N/H/F/G/M/D 1St 100 Cm                    $347.34
15366         Tiss Cltr Algc Drm F/S/N/H/F/G/M/D Ea 100 Cm                      $88.15
15400         Xenogrf Skn Temp Clsr T/A/L 1St 100 Cm                          $321.15
15401         Xenogrf Skn Temp Clsr Ea 100 Cm                                   $87.18
15410         Free Transplantation Of Skin Flap By Microsurgical Technique       $0.00
15412         Free Transplantation Of Skin Flap By Microsurgical Technique       $0.00
15414         Free Transplantation Of Skin Flap By Microsurgical Technique       $0.00
15416         Free Transplantation Of Skin Flap By Microsurgical Technique       $0.00
15420         Xenogrf Skn Temp Clsr F/S/N/H/F/G/M/D 1St 100Cm                  $371.68
15421         Xenogrf Skn Temp Clsr F/S/N/H/F/G/M/D Ea 100Cm                   $114.98
15430         Aclr Xenogrf Implt 1St 100 Cm                                   $504.80
15500         Formation Of Tube Pedicle Without Transfer, Or Major ''''del    $544.50
15505         Formation Of Tube Pedicle Without Transfer, Or Major ''''del    $544.50
15510         Formation Of Tube Pedicle Without Transfer, Or Major ''''del    $544.50
15515         Formation Of Tube Pedicle Without Transfer, Or Major ''''del    $544.50
15540         Primary Attachment Of Open Or Tubed Pedicle Flap To Recipien    $701.80
15545         Primary Attachment Of Open Or Tubed Pedicle Flap To Recipien    $701.80
15550         Primary Attachment Of Open Or Tubed Pedicle Flap To Recipien    $701.80
15555         Primary Attachment Of Open Or Tubed Pedicle Flap To Recipien    $701.80
15570         Frmj Dir/Tubed Pedcl +-Tr Trnk                                  $725.56
15572         Frmj Dir/Tubed Pedcl +-Tr Scalp Arms/Legs                       $697.33
15574         Frmj Dir/Tubed Pedcl +-Tr Ft/Ch/Ch/M/N/Ax/G/H/F                  $734.67
15576         Frmj Dir/Tubed Pedcl +-Tr E/N/E/L/Ntroral                       $702.38
15580         Cross Finger Flap, Including Free Graft To Donor Site           $535.55
15600         Delay Flap/Sctj Flap Trnk                                       $337.75
15610         Delay Flap/Sctj Flap Scalp Arms/Legs                            $238.77
15620         Delay Flap/Sctj Flap F/C/C/N/Ax/G/H/F                            $396.02
15625         Delay Of Flap Or Sectioning Of Flap (Division And Inset); Se    $166.74
15630         Delay Flap/Sctj Flap Eyelids Nose Ears/Lips                     $385.70
15650         Tr Intrm Any Pedcl Flap Any Location                            $410.01
15700         Excision Of Lesion And/Or Excisional Preparation Of Recipien    $701.80
15710         Excision Of Lesion And/Or Excisional Preparation Of Recipien    $871.20
15720         Excision Of Lesion And/Or Excisional Preparation Of Recipien    $991.80
15730         Excision Of Lesion And/Or Excisional Preparation Of Recipien   $1,144.90
15732         Musc Myoq/Fascq Flap Head&Nck                                  $1,397.76
15734         Musc Myoq/Fascq Flap Trnk                                      $1,408.16
15736         Musc Myoq/Fascq Flap Uxtr                                      $1,357.36
15738         Musc Myoq/Fascq Flap Lxtr                                      $1,418.34
15740         Flap Island Pedcl                                               $770.71
15745         Graft                                                            $968.00
15750         Flap Neurovasc Pedcl                                            $812.35
15755         Free Flap (Microvascular Transfer)                             $2,627.78
15756         Fr Musc/Myoq Flap W/Mvasc Anast                                $2,221.66
15757         Fr Skn Flap W/Mvasc Anast                                      $2,272.25
15758         Fr Fscal Flap W/Mvasc Anast                                    $2,274.77
15760         Grf Composit W/Prim Clsr Don Area                               $715.93

                                            Page 6
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
15770         Grf Derma-Fat-Fsca                                              $562.95
15775         Punch Grf Hair Trnspl 1-15 Punch Grfs                           $270.16
15776         Punch Grf Hair Trnspl > 15 Punch Grfs                           $432.60
15780         Dermabrasion Tot Face                                           $549.93
15781         Dermabrasion Sgmtl Face                                         $389.50
15782         Dermabrasion Regional Oth/Thn Face                              $328.12
15783         Dermabrasion Supfc Any Sit                                      $352.08
15785         Abrsn Skn Rmvl Scrs Tatts Actnc Chngs Prmry Or Sec              $302.50
15786         Abrasion 1 Les                                                  $140.61
15787         Abrasion Ea 4 </<                                                 $24.82
15788         Chem Peel Facial Epidrm                                         $205.29
15789         Chem Peel Facial Drm                                            $430.09
15790         Chemical Peel (Chemexfoliation); Total Face                     $298.55
15791         Chemical Peel (Chemexfoliation); Regional, Face, Hand, Or El    $214.56
15792         Chem Peel Nonfacial Epidrm                                      $189.72
15793         Chem Peel Nonfacial Drm                                         $298.99
15800         Abrsn Skn Totl Face Combnd W/Sprfcl Chemo;Face                 $1,911.80
15810         Salabrasion; 20 Sq Cm Or Less                                   $338.68
15811         Salabrasion; Over 20 Sq Cm                                      $456.93
15819         Cervicoplasty                                                   $650.62
15820         Blepharp Lwr Eyelid                                             $456.70
15821         Blepharp Lwr Eyelid W/X10Sv Hrna8 Fat Pad                       $492.27
15822         Blepharp Upr Eyelid                                             $388.56
15823         Blepharp Upr Eyelid W/Excsv Skn W8Ing Down Lid                  $563.19
15824         Rhytdct Fhd                                                     $786.50
15825         Rhytdct Nck W/Platysmal Tightening                             $2,758.80
15826         Rhytdct Glabellar Frown Lines                                   $629.20
15827         Rhytidectomy Forehead;Fat Pad                                   $798.60
15828         Rhytdct Cheek Chin&Nck                                         $2,299.00
15829         Rhytdct Smas Flap                                               $968.00
15831         Excision, Excessive Skin And Subcutaneous Tissue (Including     $826.29
15832         Exc Excsv Skn&Subq Tiss W/Lipc Thi                              $797.42
15833         Exc Excsv Skn&Subq Tiss W/Lipc Leg                              $754.80
15834         Exc Excsv Skn&Subq Tiss W/Lipc Hip                              $743.69
15835         Exc Excsv Skn&Subq Tiss W/Lipc Buttock                          $906.61
15836         Exc Excsv Skn&Subq Tiss W/Lipc Arm                              $643.83
15837         Exc Excsv Skn&Subq Tiss W/Lipc F/Arm/Hand                       $641.11
15838         Exc Excsv Skn&Subq Tiss W/Lipc Submental Fat Pad                $516.71
15839         Exc Excsv Skn&Subq Tiss W/Lipc Oth Area                         $679.28
15840         Grf Facial Nrv Palyss Fr Fsca Grf W/Obtg Fsca                    $917.90
15841         Grf Facial Nrv Palyss Fr Musc Grf W/Obtg Grf                   $1,548.24
15842         Grf Facial Nrv Palyss Fr Musc Flap Microsurg Tq                $2,451.08
15845         Grf Facial Nrv Palyss Regional Musc Tr                          $849.44
15850         Rmvl Sutrs Under Anes Sm Surgeon                                  $88.85
15851         Rmvl Sutrs Under Anes Oth Surgeon                                 $97.36
15852         Dr Chng Under Anes                                              $103.65
15860         Iv Njx Agt Tst Vasc Flo Flap/Grf                                $126.06
15876         Sucj Asstd Lipectomy Head&Nck                                      $0.00
15877         Sucj Asstd Lipectomy Trnk                                          $0.00
15878         Sucj Asstd Lipectomy Uxtr                                          $0.00
15879         Sucj Asstd Lipectomy Lxtr                                          $0.00
15920         Exc Coccygeal Pr Ulc W/Coccygectomy W/Prim Sutr                 $542.01
15922         Exc Coccygeal Pr Ulc W/Coccygectomy W/Flap Clsr                 $688.29
15931         Exc Sac Pr Ulc W/Prim Sutr                                      $601.39
15933         Exc Sac Pr Ulc W/Prim Sutr W/Ostc                               $750.06

                                             Page 7
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
15934         Exc Sac Pr Ulc W/Skn Flap Clsr                                  $837.01
15935         Exc Sac Pr Ulc W/Skn Flap Clsr W/Ostc                            $999.54
15936         Exc Sac Pr Ulc Prepj Musc/Myoq Flap/Skn Grf Clsr                $831.47
15937         Exc Sac Pr Ulc Prepj Musc/Myoq Flap/Skn Grf Ostc                 $967.59
15940         Exc Ischial Pr Ulc W/Prim Sutr                                  $623.88
15941         Exc Ischial Pr Ulc W/Prim Sutr W/Ostc Ischiect                   $836.08
15944         Exc Ischial Pr Ulc W/Skn Flap Clsr                              $804.25
15945         Exc Ischial Pr Ulc W/Skn Flap Clsr W/Ostc                        $896.29
15946         Exc Ischial Pr Ulc W/Ostc Musc/Myoq Flap/Skn                   $1,444.40
15950         Exc Trchntric Pr Ulc W/Prim Sutr                                 $519.96
15951         Exc Trchntric Pr Ulc W/Prim Sutr W/Ostc                          $745.57
15952         Exc Trchntric Pr Ulc W/Skn Flap Clsr                            $769.05
15953         Exc Trchntric Pr Ulc W/Skn Flap Clsr W/Ostc                      $869.58
15954         Excision, Trochanteric Pressure Ulcer, With Bipedicle Flap C   $1,210.00
15955         Excision, Trochanteric Pressure Ulcer, With Bipedicle Flap C    $677.60
15956         Exc Trchntric Pr Ulc Musc/Myoq Flap/Skn                        $1,055.51
15958         Exc Trchntric Pr Ulc Musc/Myoq Flap/Skn W/Ostc                 $1,065.05
15960         Excision, Heel Pressure Ulcer, With Primary Suture;             $245.40
15961         Excision, Heel Pressure Ulcer, With Primary Suture;             $677.60
15962         Excs. Heel Decubitus. W/Pinch Grft.                            $1,210.00
15964         Excision, Heel Pressure Ulcer, With Local Skin Flap Closure;    $532.40
15965         Excision, Heel Pressure Ulcer, With Local Skin Flap Closure;    $859.10
15966         Excision, Heel Pressure Ulcer, With Other Flap Closure;         $532.40
15967         Excision, Heel Pressure Ulcer, With Other Flap Closure;         $859.10
15970         Excision, Leg Pressure Ulcer, With Primary Suture;              $248.25
15971         Excision, Leg Pressure Ulcer, With Primary Suture;              $859.10
15972         Excision, Leg Pressure Ulcer, With Local Skin Flap(S);          $653.40
15973         Excision, Leg Pressure Ulcer, With Local Skin Flap(S);          $859.10
15974         Excision, Leg Pressure Ulcer, With Muscle Or Myocutaneous       $859.10
15975         Excision, Leg Pressure Ulcer, With Muscle Or Myocutaneous       $859.10
15980         Excision, Knee Pressure Ulcer, With Local Skin Flap Closure;    $653.40
15981         Excision, Knee Pressure Ulcer, With Local Skin Flap Closure;    $859.10
15982         Excision, Knee Pressure Ulcer, With Other Flap Closure;         $653.40
15983         Excision, Knee Pressure Ulcer, With Other Flap Closure;         $859.10
15999         Unlis Px Exc Pr Ulc                                                $0.00
16000         1St Tx 1St Dgr Brn No > Local Tx Is Required                      $67.48
16010         Dressings And/Or Debridement, Initial Or Subsequent; Under A      $59.84
16015         Dressings And/Or Debridement, Initial Or Subsequent; Under A    $140.72
16020         Drs&/Dbrdmt Prtl-Thkns Brns 1St/Sbsq Sm                           $80.55
16025         Drs&/Dbrdmt Prtl-Thkns Brns 1St/Sbsq Medium                     $142.17
16030         Drs&/Dbrdmt Prtl-Thkns Brns 1St/Sbsq Lg                         $166.95
16035         Escharotomy 1St Inc                                             $210.82
16036         Escharotomy Ea Inc                                                $83.21
16040         Excision Burn Wound, Without Graft, With Alloplastic Dressin    $109.17
16041         Excision Burn Wound, Without Graft, With Alloplastic Dressin    $218.83
16042         Excision Burn Wound, Without Graft, With Alloplastic Dressin    $192.91
17000         Dstrj All Prmlg 1St Les                                           $59.82
17003         Dstrj All Prmlg 2-14 Ea                                           $10.02
17004         Dstrj All Prmlg <Sk Tgs/Cutan Vasc 15>                          $194.59
17106         Dstrj Cutan Vasc Prlf < 10 Cm                                   $362.68
17107         Dstrj Cutan Vasc Prlf 10.0-50.0 Cm                              $642.28
17108         Dstrj Cutan Vasc Prlf > 50.0 Cm                                 $889.13
17110         Dstrj B9 Sk Tgs/Cutan Vasc Up 14 <                                $85.83
17111         Dstrj B9 Sk Tgs/Cutan Vasc 15/>                                   $97.73
17250         Chem Caut Granltj Tiss Proud Flesh Sinus/Fstl                     $65.62

                                             Page 8
                         MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
17260         Dstrj Mal Les T/A/L Les Diam 0.5 Cm/<                             $82.75
17261         Dstrj Mal Les T/A/L Les Diam 0.6-1.0 Cm                         $105.28
17262         Dstrj Mal Les T/A/L Les Diam 1.1-2.0 Cm                         $131.26
17263         Dstrj Mal Les T/A/L Les Diam 2.1-3.0 Cm                         $146.49
17264         Dstrj Mal Les T/A/L Les Diam 3.1-4.0 Cm                         $157.93
17266         Dstrj Mal Les T/A/L Les Diam > 4.0 Cm                           $185.05
17270         Dstrj Mal Les S/N/H/F/G Les Diam 0.5 Cm/<                       $114.58
17271         Dstrj Mal Les S/N/H/F/G Les Diam 0.6-1.0 Cm                     $123.85
17272         Dstrj Mal Les S/N/H/F/G Les Diam 1.1-2.0 Cm                     $142.37
17273         Dstrj Mal Les S/N/H/F/G Les Diam 2.1-3.0 Cm                     $161.72
17274         Dstrj Mal Les S/N/H/F/G Les Diam 3.1-4.0 Cm                     $196.21
17276         Dstrj Mal Les S/N/H/F/G Les Diam > 4.0 Cm                       $235.26
17280         Dstrj Mal Les F/E/E/N/L/M Les Diam 0.5 Cm/<                     $105.28
17281         Dstrj Mal Les F/E/E/N/L/M Les Diam 0.6-1.0 Cm                   $137.22
17282         Dstrj Mal Les F/E/E/N/L/M Les Diam 1.1-2.0 Cm                   $159.88
17283         Dstrj Mal Les F/E/E/N/L/M Les Diam 2.1-3.0 Cm                   $197.34
17284         Dstrj Mal Les F/E/E/N/L/M Les Diam 3.1-4.0 Cm                   $234.13
17286         Dstrj Mal Les F/E/E/N/L/M Les Diam > 4.0 Cm                     $311.87
17300         Chemosurgery Mohls Type Malignant Removal Etc                   $387.20
17301         Subsequent Stages To 5 Microscopic Sections                     $121.00
17302         Subsequent Trtmnt, Over 5 Add Micro Section                       $18.15
17303         Chemosurgery (Mohs'''''''' Micrographic Technique), First St    $248.20
17304         Chemosurgery (Mohs Micrographic Technique), Including Remova    $593.86
17305         Chemosurgery (Mohs Micrographic Technique), Including Remova    $251.24
17306         Chemosurgery (Mohs Micrographic Technique), Including Remova    $251.97
17307         Chemosurgery (Mohs Micrographic Technique), Including Remova    $250.14
17310         Chemosurgery (Mohs Micrographic Technique), Including Remova      $98.16
17340         Crtx Co2 Slush Liq N2 Acne                                        $43.92
17360         Chem Exfoliation Acne                                           $109.55
17380         Electrolss Epilation Ea 1/2 Hr                                    $30.25
17999         Unlis Px Skn Muc Memb&Subq Tiss                                    $0.00
19000         Pnxr Aspir Cst Brst                                             $108.75
19001         Pnxr Aspir Cst Brst Ea Cst                                        $46.16
19020         Mastotomy W/Expl/Drg Absc Dp                                    $369.11
19030         Njx Px Only Mam Duxo/Glcto                                      $183.44
19100         Bx Brst Prq Ndl Core X W/Img Gdn Spx                            $130.81
19101         Bx Brst Opn Incal                                               $299.76
19102         Bx Brst Prq Ndl Core W/Img Gdn                                  $226.52
19103         Breast Biopsy Through Skin With Sampling Device                 $586.26
19110         Nppl Expl +-Exc Sltry Lactf Dux/Paplm Lactf Dux                 $394.27
19112         Exc Lactf Dux Fstl                                              $367.17
19120         Exc Cyst/Aberrant Breast Tissue Open 1/> Les                    $402.14
19121         Excis Cyst, Fbrdnma, Bngn Tmr 1 Or More Lsn;Bilat               $484.00
19125         Exc Brst Les Preop Plmt Rad Marker Opn 1 Les                    $432.38
19126         Exc Brst Les Preop Plmt Rad Marker Opn Ea Addl                  $160.93
19140         Mastectomy For Gynecomastia                                     $483.38
19141         Mastctmy For Gyncmsta Thu Inc. Bilateral                        $786.50
19160         Mastectomy, Partial (Eg, Lumpectomy, Tylectomy, Quadrantecto    $379.37
19161         Mstctmy,Part(Qdrctmy Or More); Bilateral                        $629.20
19162         Mastectomy, Partial (Eg, Lumpectomy, Tylectomy, Quadrantecto    $804.96
19180         Mastectomy, Simple, Complete                                    $556.11
19181         Mastectomy Complete Simple Bilateral                            $931.70
19182         Mastectomy, Subcutaneous                                        $502.55
19183         Mastectomy, Subcutaneous; Bilateral                            $1,173.70
19184         Mastctmy,Subctns,W/Immdte Implnt; Unilat                       $1,270.50

                                           Page 9
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
19185         Mastctmy,Subctns,W/Immediate Implnt; Bilat                     $1,391.50
19186         Mastctmy,Subctns W/Delayed Implnt; Unlat                       $1,512.50
19187         Mastctmy,Subctns,W/Delayed Implnt; Bilat                       $2,383.70
19200         Mastectomy, Radical, Including Pectoral Muscles, Axillary Ly    $945.27
19205         Mstctmy,Rdcl,Incl Breast,Mscl,Node; Bilat                      $1,936.00
19211         Mstctmy,Rdcl,W/Immediate Implnt; One                           $2,420.00
19212         Mastectomy, Radical W/Immed Implt. Two                         $2,904.00
19215         Mstctmy,Radical W/Delayed Implnt; Uilat                        $2,178.00
19216         Mstctmy,Radical W/Delayed Implnt; Bilat                        $2,565.20
19220         Mastectomy, Radical, Including Pectoral Muscles, Axillary An    $965.79
19221         Mstctmy,Rdcl,Incl Breast,Mscl & Nodes; Bilat                   $1,996.50
19224         Mastectomy, Radical W/Immd Implt One                           $2,420.00
19225         Mastectomy, Radical, W/Immed Implant Two                       $2,904.00
19228         Mastectomy, Radical W/Delay Implnt One                         $2,178.00
19229         Mastectomy, Radical W/Delay Implnt Two                         $2,662.00
19240         Mastectomy, Modified Radical, Including Axillary Lymph Nodes    $978.36
19245         Mstctmy,Mdfd Rdcl W/Dsscton Not Mscl;Bilat                     $1,754.50
19250         Mastectomy Modified W/Immed Implnt One                         $2,238.50
19251         Mastectomy Modified W/Immed Implnt Two                         $2,722.50
19254         Mastectomy Modified W/Delay Implnt One                         $1,996.50
19255         Mstctmy,Mod.W/Delay Implnt; Bilat                              $2,480.50
19260         Exc Ch Wal Tum Rib                                             $1,068.95
19271         Exc Ch Wal Tum Rib W/Rcnstj W/O Medstnl Lmphadec               $1,481.75
19272         Exc Ch Wal Tum Rib W/Rcnstj W/Medstnl Lmphadec                 $1,628.41
19290         Preop Plmt Ndl Loclzj Wire Brst                                 $160.18
19291         Preop Plmt Ndl Loclzj Wire Brst Ea Les                            $89.05
19295         Image Gid Plmt Mtlc Loclzj Clip Prq Brst Bx                     $101.56
19296         Plmt Radthx Balo Cath Brst Ntrstl Prtl Mast                    $4,832.84
19297         Plmt Radthx Balo Cath Brst Ntrstl Prtl Mast Img                   $95.96
19298         Plmt Radthx Brachytx Brst Ntrstl Prtl Mast Img                 $1,818.60
19300         Mast Gynecomastia                                              $1,633.50
19301         Mast Prtl                                                      $2,420.00
19303         Mast Smpl Compl                                                $1,633.50
19304         Mast Subq                                                      $2,420.00
19311         Mammoplsty,Agmntaton,Prsthtc (Not Impl) Bilat                  $1,331.00
19316         Mastopexy                                                       $732.12
19318         Rdctj Mammaplasty                                              $1,074.47
19324         Mammaplasty Agmntj W/O Prostc Implt                             $428.64
19325         Mammaplasty Agmntj W/Prostc Implt                               $600.13
19328         Rmvl Ntc Mam Implt                                              $426.96
19330         Rmvl Mam Implt Matrl                                            $544.55
19331         Removal Mannary Implnt Mat; Bilat                                  $0.00
19340         Immt Insj Brst Prosth Flwg Mastopexy Mast/Rcnstj                $383.27
19342         Dlyd Insj Brst Prosth Flwg Mastopexy Mast/Rcnstj                $804.40
19350         Nppl/Areola Rcnstj                                              $898.01
19351         Reconst. Nipple &/Or Areola,Incl Grft.; Bilat                   $733.56
19355         Corrj Inverted Nppls                                            $788.75
19357         Brst Rcnstj Immt/Dlyd W/Tiss Expander Sbsq Xpnsj               $1,278.72
19360         Breast Reconstruction With Muscle Or Myocutaneous Flap         $2,132.50
19361         Brst Rcnstj W/Latsms D/Si Flap Wo Prsthc Impl                  $1,250.31
19362         Breast Reconstruction With Transverse Rectus Abdominis Flap    $1,990.12
19364         Brst Rcnstj W/Fr Flap                                          $2,583.92
19366         Brst Rcnstj W/Oth Tq                                           $1,315.01
19367         Brst Rcnstj Tram Flap 1 Pedcl Clsr Don Sit                     $1,700.61
19368         Brst Rcnstj Tramflap 1 Pedcl Clsr Don Sit Mvasc                $2,120.58

                                             Page 10
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                          Amount
19369         Brst Rcnstj Tram Flap 2 Pdcl W/Clsr Don Sit        $1,993.69
19370         Opn Priprostc Capsul Brst                           $596.30
19371         Priprostc Capslctomy Brst                           $685.76
19380         Revj Rcnsted Brst                                   $672.28
19396         Prepj Moulage Custom Brst Implt                     $303.48
19499         Unlis Px Brst                                          $0.00
20000         Inc Soft Tiss Absc Supfc                            $173.88
20005         Inc Soft Tiss Absc Dp/Comp                          $265.97
20010         Incision Of Soft Tissue Abscess;                      $36.30
20100         Expl Pentrg Wnd Spx Nck                             $635.47
20101         Expl Pentrg Wnd Spx Ch                              $240.12
20102         Expl Pentrg Wnd Spx Abd/Flank/Bk                    $292.00
20103         Expl Pentrg Wnd Spx Xtr                             $376.77
20150         Exc Epiphysl Bar +-Autog Soft Tiss Grf Sm Fscal     $820.89
20200         Bx Musc Supfc                                       $179.55
20205         Bx Musc Dp                                          $250.31
20206         Bx Musc Prq Ndl                                     $155.57
20220         Bx B1 Trocar/Ndl Supfc                              $222.99
20225         Bx B1 Trocar/Ndl Dp                                 $254.77
20240         Bx B1 Opn Supfc                                     $231.82
20245         Bx B1 Opn Dp                                        $543.92
20250         Bx Vrt Bdy Opn Thrc                                 $377.63
20251         Bx Vrt Bdy Opn Lmbr/Crv                             $434.67
20500         Njx Sinus Trc Ther Spx                              $265.52
20501         Njx Sinus Trc Dx Sinogram                           $140.65
20520         Rmvl Fb Musc/Tdn Shth Smpl                          $159.78
20525         Rmvl Fb Musc/Tdn Shth Dp/Comp                       $275.09
20526         Njx Ther Carpl Tunnel                                 $73.37
20550         Njx 1 Tdn Shth/Ligm Aponeurosis                       $56.78
20551         Njx 1 Tdn Origin/Insj                                 $55.68
20552         Njx 1/Mlt Trigger Point 1/2 Musc                      $54.15
20553         Njx 1/Mlt Trigger Point 3/> Musc                      $61.53
20600         Arthrocnts Aspir&/Njx Sm Jt/Bursa                     $50.86
20605         Arthrocnts Aspir&/Njx Intrm Jt/Bursa                  $55.63
20610         Arthrocnts Aspir&/Njx Major Jt/Bursa                  $67.89
20612         Aspir&/Njx Ganglion Cst Any Location                  $54.91
20615         Aspir&Njx Tx B1 Cst                                 $187.24
20650         Insj Wire/Pin W/Appl Skel Tracj W/Rmvl Spx          $185.47
20660         Appl Crnl Tng Calipr/Strtctc Frame W/Rmvl Spx       $229.43
20661         Appl Halo Rmvl Crnl                                 $408.14
20662         Appl Halo Rmvl Pel                                  $464.43
20663         Appl Halo Rmvl Fem                                  $414.03
20664         Appl Halo Rmvl Crnl 6/> Pins Thin Skl Ostlg Anes    $630.53
20665         Rmvl Tng/Halo Applied Axh Phys                      $132.32
20670         Rmvl Implt Supfc Spx                                $320.65
20680         Rmvl Implt Dp                                       $264.67
20690         Appl Uniplne Uni Xtrnl Fixj Sys                     $244.45
20692         Appl Multiplne Uni Xtrnl Fixj Sys                   $404.47
20693         Adjustment/Revj Xtrnl Fixj Sys Req Anes             $462.64
20694         Rmvl Under Anes Xtrnl Fixj Sys                      $433.53
20802         Rplj Arm W/N/H/E Jt Compl Amp                      $2,600.93
20804         Replantation, Arm                                      $0.00
20805         Rplj F/Arm W/Rds/U R/Cjt Compl Amp                 $3,338.23
20806         Replantation, Forearm                                  $0.00
20808         Rplj Hand W/Hand Thru Mtcarphlngl Jts Compl Amp    $4,203.04

                                            Page 11
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                  Amount
20812         Replantation, Hand                                             $0.00
20816         Rplj Dgt Ex Thmb Mtcarphlngl Jt Compl Amp                  $2,731.42
20820         Replantation, Digit, Excluding Thumb                           $0.00
20822         Rplj Dgt Excluding Thmb Sublimis Tdn Compl Amp             $2,415.48
20823         Replantation, Digit, Excluding Thumb                           $0.00
20824         Rplj Thmb Carp/Mtcrpl Jt Mp Jt Compl Amp                   $2,716.27
20826         Replantation, Thumb                                            $0.00
20827         Rplj Thmb Dstl Tip Mp Jt Compl Amp                         $2,527.87
20828         Replantation, Thumb; Incomplete Amputation                     $0.00
20832         Replantation, Leg; Complete Amputation                         $0.00
20834         Replantation, Leg; Incomplete Amputation                       $0.00
20838         Rplj Foot Compl Amp                                        $2,660.14
20840         Replantation, Foot; Incomplete Amputation                      $0.00
20900         Obtaining Small Amount Of Bone For Graft                    $512.75
20902         B1 Grf Any Don Area Major/Lg                                $584.12
20910         Crtlg Grf Costochondral                                     $483.06
20912         Crtlg Grf Nsl Septum                                        $485.96
20920         Fsca Lata Grf Strippr                                        $383.92
20922         Fsca Lata Grf Inc&Area Expos Cplx/Sheet                     $535.32
20924         Tdn Grf From Distance                                       $498.04
20926         Tiss Grfs Oth                                                $421.94
20930         Algrft Spi Surg Only Morselized                                $0.00
20931         Algrft Spi Surg Only Structural                             $118.23
20936         Agrft Spi Surg Only Local Obt From Sm Inc                      $0.00
20937         Agrft Spi Surg Only Morselized Sep Inc                      $178.65
20938         Agrft Spi Surg Only Bicort/Tricort Sep Inc                   $195.36
20950         Mntr Ntrstl Flu Press Dev Cmprt Synd                        $104.44
20955         B1 Grf W/Mvasc Anast Fibula                                $2,588.69
20956         B1 Grf W/Mvasc Anast Iliac Crest                           $2,655.04
20957         B1 Grf W/Mvasc Anast Metar                                 $2,493.88
20960         Bone Graft With Microvascular Anastomosis; Rib                 $0.00
20962         B1 Grf W/Mvasc Anast Oth/Iliac Crest/Metar                 $2,683.15
20969         Fr Ostq Flap W/Mvasc Anast Metar/Grt Toe                   $2,853.55
20970         Fr Ostq Flap W/Mvasc Anast Iliac Crest                     $2,776.99
20971         Free Osteocutaneous Flap With Microvascular Anastomosis;       $0.00
20972         Fr Ostq Flap W/Mvasc Anast Metar                           $2,696.49
20973         Fr Ostq Flap W/Mvasc Anast Grt Toe W/Web Space             $2,857.75
20974         Elec Stimj Aid B1 Hlg Noninvasive                             $50.27
20975         Elec Stimj Aid B1 Hlg Invasive                              $181.01
20976         Electrical Stimulation To Aid Bone Healing Percutaneous        $0.00
20979         Lw Ntsty Us Stimj Aid B1 Hlg Noninvasive                      $53.30
20982         Abltj B1 Tum Rf Prq Ct Gdn                                 $4,146.48
20999         Unlis Px Muscskel Sys General                                  $0.00
21010         Arthrt Tmprmand Jt                                           $669.05
21011         Arthrotomy, Temporomandibular Joint                           $60.50
21015         Rad Rescj Tum Soft Tiss Face/Scalp                          $424.71
21025         Exc B1 Mndbl                                                $785.99
21026         Exc B1 Facial B1                                            $453.67
21029         Rmvl Cntrg B9 Tum Facial B1                                 $637.76
21030         Exc B9 Tum/Cst Maxl/Zygoma Encl&Curtg                       $446.72
21031         Exc Torus Mndblris                                          $302.05
21032         Exc Max Torus Palatinus                                     $303.47
21034         Exc Mal Tum Maxl/Zygoma                                    $1,165.31
21040         Exc B9 Tum/Cst Mndbl Encl&/Curtg                            $427.87
21041         Removal Of Jaw Bone Lesion                                  $494.67

                                            Page 12
                           MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                   Amount
21044         Exc Mal Tum Mndbl                                            $801.77
21045         Exc Mal Tum Mndbl Rad Rescj                                 $1,079.39
21046         Exc B9 Tum/Cst Mndbl Intra-Oral Osteot                       $997.68
21047         Exc B9 Tum/Cst Mndbl Xtr-Oral Osteot&Prtl Mndblc            $1,265.02
21048         Exc B9 Tum/Cst Maxl Intra-Oral Osteot                       $1,026.57
21049         Exc B9 Tum/Cst Maxl Xtr-Oral Osteot&Prtl Maxlct             $1,196.41
21050         Condylectomy Tmprmand Jt Spx                                 $817.14
21060         Meniscectomy Prtl/Compl Tmprmand Jt Spx                      $796.05
21070         Coronoidectomy Spx                                           $595.47
21071         Coronoidectomy (Separate Procedure)                         $1,452.00
21076         I&Cust Prep Surg Obturator Prosth                           $1,031.18
21077         I&Cust Prep Orb Prosth                                      $2,602.57
21079         I&Cust Prep Interim Obturator Prosth                        $1,722.16
21080         I&Cust Prep Definitive Obturator Prosth                     $1,981.96
21081         I&Cust Prep Mndblr Rescj Prosth                             $1,783.18
21082         I&Cust Prep Palatal Agmntj Prosth                           $1,575.68
21083         I&Cust Prep Palatal Lift Prosth                             $1,522.12
21084         I&Cust Prep Sp Aid Prosth                                   $1,745.54
21085         I&Cust Prep Oral Surg Splnt                                  $678.52
21086         I&Cust Prep Aur Prosth                                      $1,907.46
21087         I&Cust Prep Nsl Prosth                                      $1,910.39
21088         I&Cust Prep Facial Prosth                                       $0.00
21089         Unlis Maxlfcl Prostc Px                                         $0.00
21100         Appl Halo Typ Applc Maxlfcl Fixj Rmvl Spx                    $371.36
21110         Appl Ntrdntl Fixj Dev Non-Fx Dislc W/Rmvl                    $464.33
21116         Njx Tmprmand Jt Arthg                                        $299.98
21120         Geniop Agmntj Agrft Algrft Prostc Matrl                      $520.38
21121         Geniop Sliding Osteot 1 Piece                                $693.42
21122         Geniop Sliding Osteot 2/> Osteot                             $605.17
21123         Geniop Sliding Agmntj W/Interposal B1 Grfs                   $774.54
21125         Agmntj Mndblr Bdy/Angl Prostc Matrl                          $862.80
21127         Agmntj Mndblr Bdy/Angl W/B1 Grf Onlay/Interposal             $982.10
21137         Rdctj Fhd Cntrg Only                                         $664.01
21138         Rdctj Fhd Cntrg&Appl Prostc Matrl/B1 Grf                     $866.39
21139         Rdctj Fhd Cntrg&Setbk Ant Frnt Sinus Wall                    $951.94
21141         Rcnstj Mdfc Left I 1 Piece W/O B1 Grf                       $1,261.70
21142         Rcnstj Mdfc Left I 2 Pieces W/O B1 Grf                      $1,235.80
21143         Rcnstj Mdfc Left I 3/> Piece W/O B1 Grf                     $1,288.82
21144         Reconstruction Midface, Lefort I; Intrusion, Single Piece   $1,322.30
21145         Rcnstj Mdfc Left I 1 Piece W/B1 Grfs                        $1,362.65
21146         Rcnstj Mdfc Left I 2 Pieces W/B1 Grfs                       $1,446.01
21147         Rcnstj Mdfc Left I 3/> Piece W/B1 Grfs                      $1,444.52
21150         Rcnstj Mdfc Left Ii Ant Intrusion                           $1,509.82
21151         Rcnstj Mdfc Left Ii Dirion W/B1 Grfs                        $1,806.79
21154         Rcnstj Mdfc Left Iii W/B1 Grfs W/O Left I                   $2,113.05
21155         Rcnstj Mdfc Left Iii W/B1 Grfs W/Left I                     $2,367.73
21159         Rcnstj Mdfc Left Iii W/Fhd W/B1 Grfs W/O Left I             $2,804.54
21160         Rcnstj Mdfc Left Iii W/Fhd W/B1 Grfs W/Left I               $2,837.98
21172         Rcnstj Suprior-Lat Orb Rim&Lwr Fhd                          $1,643.87
21175         Rcnstj Bifrnt Suprior-Lat Orb Rims&Lwr Fhd                  $2,158.36
21179         Rcnstj Fhd&/Supraorb Rims W/Grfs                            $1,493.95
21180         Rcnstj Fhd&/Supraorb Rims W/Agrft                           $1,631.25
21181         Rcnstj Cntrg B9 Tum Crnl B1S Xtrc                            $702.07
21182         Rcnstj Orbit/Fhd/Nasethmd Exc B9 Tum Grf <40 Cm             $2,042.06
21183         Rcnstj Orbit/Fhd/Nasethmd Exc B9 Grf >40 <80 Cm             $2,231.61

                                               Page 13
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
21184         Rcnstj Orbit/Fhd/Nasethmd Exc B9 Tum Grf>80 Cm                 $2,451.25
21188         Rcnstj Mdfc Osteot&B1 Grfs                                     $1,482.55
21193         Rcnstj Mndblr Rami Hrzntl Ver C/L Osteot W/O B1                $1,188.12
21194         Rcnstj Mndblr Rami Hrzntl Ver C/L Osteot W/B1                  $1,321.44
21195         Rcnstj Mndblr Rami&/Bdy Sgtl Splt W/O Int Rgd                  $1,185.79
21196         Rcnstj Mndblr Rami&/Bdy Sgtl Splt W/Int Rgd Fixj               $1,291.13
21198         Osteot Mndbl Sgmtl                                              $977.66
21199         Osteot Mndbl Sgmtl W/Genioglossus Advmnt                        $994.09
21200         Osteotomy (Eg, For Prognathism, Micrognathism, Apertognathis   $1,633.50
21202         Osteotomy (Eg, For Prognathism, Micrognathism, Apertognathis   $1,633.50
21203         Osteotomy (Eg, For Prognathism, Micrognathism, Apertognathis       $0.00
21204         Osteotomy (Eg, For Prognathism, Micrognathism, Apertognathis   $1,633.50
21206         Osteot Maxl Sgmtl                                               $970.10
21208         Ostpl Facial B1S Agmntj Algrft/Prostc Implt                     $955.51
21209         Ostpl Facial B1S Rdctj                                          $714.01
21210         Grf B1 Nsl Max/Malar Areas                                      $924.26
21215         Grf B1 Mndbl                                                    $944.48
21230         Grf Rib Crtlg Autog F/C/N/E                                     $761.53
21235         Grf Ear Crtlg Autog Nose/Ear                                    $691.36
21240         Arthrp Tmprmand Jt +-Agrft                                     $1,044.17
21241         Arthrplsty Tmj Joint; Bilateral                                $1,391.50
21242         Arthrp Tmprmand Jt W/Algrft                                     $997.41
21243         Arthrp Tmprmand Jt W/Prostc Jt Rplcmt                          $1,518.42
21244         Rcnstj Mndbl Xtroral W/Transosteal B1 Plate                     $856.23
21245         Rcnstj Mndbl/Maxl Subpriosteal Implt Prtl                      $1,073.12
21246         Rcnstj Mndbl/Maxl Subpriosteal Implt Compl                     $1,055.58
21247         Rcnstj Mndblr Condyle W/B1 Cartlg Agrfts                       $1,607.22
21248         Rcnstj Mndbl/Maxl Endosteal Implt Prtl                          $952.98
21249         Rcnstj Mndbl/Maxl Endosteal Implt Compl                        $1,326.84
21250         Osteoplasty Of Maxilla And/Or Other Facial Bones For Midface   $1,633.50
21254         Osteoplasty Of Maxilla And/Or Other Facial Bones For Midface   $1,633.50
21255         Rcnstj Zygmtc Arch/Glenoid Fossa W/B1 Cartlg                   $1,145.18
21256         Rcnstj Orbit W/Osteot&W/B1 Grfs                                $1,099.02
21260         Pri/Bital Osteot Hyptlsm W/B1 Grfs Xtrc                        $1,004.70
21261         Pri/Bital Osteot Hyptlsm W/B1 Grfs Intra-&Xtrc                 $1,983.21
21263         Pri/Bital Osteot Hyptlsm W/B1 Grfs W/Fhd                       $1,635.45
21267         Orb Rpsg Osteot Uni W/B1 Grfs Xtrc                             $1,253.64
21268         Orb Rpsg Osteot Uni W/B1 Grfs Intra-&Xtrc                      $1,510.61
21270         Malar Agmntj Prostc Matrl                                       $851.57
21275         Sec Revj Orbitocranfcl Rcnstj                                   $788.54
21280         Medial Canthopexy Spx                                           $459.85
21282         Lat Canthopexy                                                  $311.00
21295         Rdctj Masseter Musc&B1 Xtroral Appr                             $166.61
21296         Rdctj Masseter Musc&B1 Intraoral Appr                           $334.73
21299         Unlis Cranfcl&Maxlfcl Px                                           $0.00
21300         Closed Treatment Of Skull Fracture Without Operation            $118.27
21310         Cltx Nsl B1 Fx W/O Mnpj                                         $109.54
21315         Cltx Nsl B1 Fx W/O Stablj                                       $172.72
21320         Cltx Nsl B1 Fx W/Stablj                                         $231.59
21325         Optx Nsl Fx Uncomp                                              $292.38
21330         Optx Nsl Fx Comp W/Int&/Xtrnl Skel Fixj                          $416.91
21335         Optx Nsl Fx W/Concomitant Optx Fxd Septum                       $601.11
21336         Optx Nsl Septal Fx +-Stablj                                     $456.83
21337         Cltx Nsl Septal Fx +-Stablj                                     $298.40
21338         Optx Nasoethmoid Fx W/O Xtrnl Fixj                              $485.60

                                            Page 14
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                  Amount
21339         Optx Nasoethmoid Fx W/Xtrnl Fixj                            $585.61
21340         Prq Nasoethmoid Cplx Splnt Wire/Hdcp Fixj                   $760.98
21343         Optx Deprs Frnt Sinus Fx                                    $905.14
21344         Optx Comp Frnt Sinus Fx Via Coronal/Mlt Appr               $1,320.05
21345         Cltx Nasomax Cplx Fx Left Ii Typ W/Ntrdntl Fixj             $755.00
21346         Optx Nasomax Cplx Fx Left Ii Typ W/Wirg&Fixj                $918.60
21347         Optx Nasomax Cplx Fx Left Ii Typ Req Mlt Opn                $885.58
21348         Optx Nasomax Cplx Fx Left Ii Typ W/B1 Grfg                 $1,108.70
21350         Trtmnt Clsd Or Opn Fx Mlr Incl Zygmtc Arch W/O Man          $133.10
21355         Prq Tx Fx Malar Area W/Zygmtc Arch&Malar Tripod             $326.26
21356         Optx Deprs Zygmtc Arch Fx                                   $598.22
21360         Optx Deprs Malar Fx W/Zygmtc Arch&Malar Tripod              $773.67
21365         Optx Comp Fx Malar Area W/Zygmtc Arch W/Int Fx             $1,051.14
21366         Optx Comp Fx Malar Area W/Zygmtc Arch W/B1 Grf             $1,156.60
21380         Orb Floor "Blowout" Fx W/O Manip.                           $133.10
21385         Optx Orb Floor Blwt Fx Transantral Appr Caldwell            $631.14
21386         Optx Orb Floor Blwt Fx Pri/Bital Appr                       $652.22
21387         Optx Orb Floor Blwt Fx Cmbn Appr                            $675.39
21390         Optx Orb Floor Blwt Fx Pri/Bital Appr W/Allplstc            $704.16
21395         Optx Orb Floor Blwt Fx Pri/Bital Appr W/B1 Grf              $866.33
21400         Cltx Fx Orbit Xcp Blwt W/O Mnpj                             $193.81
21401         Cltx Fx Orbit Xcp Blwt W/Mnpj                               $322.81
21406         Optx Fx Orbit Xcp Blwt W/O Implt                            $522.13
21407         Optx Fx Orbit Xcp Blwt W/Implt                              $614.79
21408         Optx Fx Orbit Xcp Blwt W/B1 Grfg                            $858.85
21420         Trtmnt Clsd Opn Mxllry Fx W/O Manpltn                       $133.10
21421         Cltx Palatal/Max Fx Left I Typ Fixj/Splnt                   $574.54
21422         Optx Palatal/Max Fx Left I Typ                              $755.95
21423         Optx Palatal/Max Fx Left I Typ Comp Mlt Appr                $744.39
21431         Cltx Cranfcl Sep Left Iii Typ W/Fixj/Splnt                  $680.60
21432         Optx Cranfcl Sep Left Iii Typ W/Wirg&/Int Fixj              $574.00
21433         Optx Cranfcl Sep Left Iii Typ Comp Mlt Appr                $1,680.45
21435         Optx Cranfcl Sep Left Iii Typ Comp W/Int&/Xtrnl            $1,197.59
21436         Optx Cranfcl Sep Left Iii Typ Comp Int Fixj W/B1           $1,832.03
21440         Cltx Mndblr/Max Alveolar Ridge Fx Spx                       $405.75
21445         Optx Mndblr/Max Alveolar Ridge Fx Spx                       $608.95
21450         Cltx Mndblr Fx W/O Mnpj                                     $511.18
21451         Cltx Mndblr Fx W/Mnpj                                       $520.83
21452         Prq Tx Mndblr Fx W/Xtrnl Fixj                               $367.50
21453         Cltx Mndblr Fx W/Ntrdntl Fixj                               $613.91
21454         Optx Mndblr Fx W/Xtrnl Fixj                                 $506.50
21455         Closed Manipulative Treatment By Interdental Fixation Of    $562.35
21461         Optx Mndblr Fx W/O Ntrdntl Fixj                             $794.68
21462         Optx Mndblr Fx W/Ntrdntl Fixj                               $917.64
21465         Optx Mndblr Condylar Fx                                     $852.03
21470         Optx Comp Mndblr Fx Mlt Surg W/Int Fixj                    $1,085.71
21480         Cltx Tmprmand Dislc 1St/Sbsq                                  $96.42
21485         Cltx Tmprmand Dislc Comp 1St/Sbsq                           $380.57
21490         Optx Tmprmand Dislc                                         $867.89
21493         Closed Treatment Of Hyoid Fracture; Without Manipulation    $156.01
21494         Closed Treatment Of Hyoid Fracture; With Manipulation       $463.82
21495         Optx Hyoid Fx                                               $450.75
21497         Ntrdntl Wirg Condition Oth/Thn Fx                           $397.62
21499         Unlis Muscskel Px Head                                         $0.00
21501         I&D Dp Absc/Hmtma Soft Tiss Nck/Thorax                      $331.01

                                             Page 15
                           MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
21502         I&D Dp Absc/Hmtma Soft Tiss Nck/Thorax Prtl Rib                 $512.27
21510         Inc Dp W/Opng B1 Cortex Thorax                                  $455.78
21511         Incision, Deep, With Opening Of Bone Cortex                     $338.80
21550         Bx Soft Tiss Nck/Thorax                                          $216.34
21555         Exc Tum Soft Tiss Nck/Thorax Subq                               $366.76
21556         Exc Tum Soft Tiss Nck/Thorax Dp Subfscal Im                      $382.91
21557         Rad Rescj Tum Soft Tiss Nck/Thorax                              $571.75
21600         Exc Rib Prtl                                                    $508.56
21610         Costotransvrsctomy Spx                                          $965.61
21615         Exc 1St&/Crv Rib                                                $672.91
21616         Exc 1St&/Crv Rib W/Sympth                                       $807.05
21620         Ostectomy Sternum Prtl                                          $512.65
21627         Sternal Dbrdmt                                                  $530.08
21630         Rad Rescj Sternum                                              $1,181.27
21632         Rad Rescj Sternum W/Medstnl Lmphadec                           $1,190.65
21633         Radical Resection Of Sternum; For Osteomyelitis                $1,233.91
21685         Hyoid Myotomy&Ssp                                               $914.95
21700         Div Scalenus Anticus W/O Rescj Crv Rib                          $467.82
21705         Div Scalenus Anticus Rescj Crv Rib                              $608.83
21720         Div Strncldmstd Ticollis Opn W/O Cst Appl                       $450.52
21725         Div Strncldmstd Ticollis Opn Cst Appl                           $506.54
21740         Rcnstv Pectus Excavatm/Carinatm Opn                            $1,029.07
21741         Xiphoid Resection Pectus Excavatum                                 $0.00
21742         Rcnstv Pectus Excavatm/Carinatm Minly W/O Thrsc                    $0.00
21743         Rcnstv Pectus Excavatm/Carinatm Minly Invasive                     $0.00
21750         Clsr Median Sterxomy Sep +-Dbrdmt Spx                           $691.92
21800         Cltx Rib Fx Uncomp Ea                                           $117.00
21805         Optx Rib Fx W/O Fixj Ea                                          $239.25
21810         Tx Rib Fx Req Xtrnl Fixj Flail Ch                               $468.74
21820         Cltx Sternum Fx                                                 $151.15
21825         Optx Sternum Fx +-Skel Fixj                                     $561.69
21899         Unlis Px Nck/Thorax                                                $0.00
21920         Bx Soft Tiss Bk/Flank Supfc                                      $202.39
21925         Bx Soft Tiss Bk/Flank Dp                                         $430.94
21930         Exc Tum Soft Tiss Bk/Flank                                       $410.43
21935         Rad Rescj Tum Soft Tiss Bk/Flank                               $1,133.90
22010         I&D Opn Dp Absc Pst Spi Crv Thrc/Cervicothrc                    $823.82
22015         I&D Opn Dp Absc Pst Spi Lmbr Sac/Lumbosac                       $816.58
22100         Prtl Exc Pst Vrt Intrnsc B1Y Les 1 Vrt Sgm Crv                   $717.64
22101         Prtl Exc Pst Vrt Intrnsc B1Y Les 1 Vrt Sgm Thrc                  $727.36
22102         Prtl Exc Pst Vrt Intrnsc B1Y Les 1 Vrt Sgm Lmbr                  $732.58
22103         Prtl Exc Pst Vrt Intrnsc B1Y Les 1 Vrt Sgm Ea                    $149.87
22105         Partial Resection Of Vertebral Component For Tumor             $1,079.07
22106         Partial Resection Of Vertebral Component For Tumor              $945.83
22107         Partial Resection Of Vertebral Component For Tumor              $733.06
22110         Prtl Exc Vrt Bdy B1Y Les W/O Spi Cord 1 Sgm Crv                  $921.28
22111         Partial Excision (Craterization, Saucerization) Of Vertebrae   $1,246.30
22112         Prtl Exc Vrt Bdy B1Y Les W/O Spi Cord 1 Sgm Thrc                 $914.29
22113         Partial Excision (Craterization, Saucerization) Of Vertebrae   $1,246.30
22114         Prtl Exc Vrt Bdy B1Y Les W/O Spi Cord 1 Sgm Lmbr                 $914.78
22115         Partial Excision (Craterization, Saucerization) Of Vertebrae   $1,246.30
22116         Prtl Exc Vrt Bdy B1Y Les W/O Spi Cord 1 Sgm Ea                   $148.88
22120         Radical Resection Of Vertebral Body Or Component               $2,129.60
22128         Radical Resection Of Vertebral Body Or Component                $677.60
22129         Radical Resection Of Vertebral Body Or Component                $677.60

                                               Page 16
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
22130         Radical Resection Of Vertebral Body Or Component                $677.60
22140         Reconstruction Of Spine With Bone Graft (Autograft, Allograf   $1,769.83
22141         Reconstruction Of Spine With Bone Graft (Autograft, Allograf   $1,922.11
22142         Reconstruction Of Spine With Bone Graft (Autograft, Allograf   $2,123.88
22145         Reconstruction Of Spine Following Vertebral Body Resection,     $619.70
22148         Harvesting Of Bone Autograft For Vertebral Reconstruction       $327.40
22150         Reconstruction Of Spine With Prefabricated Prosthetic Replac   $1,796.06
22151         Reconstruction Of Spine With Prefabricated Prosthetic Replac   $1,820.17
22152         Reconstruction Of Spine With Prefabricated Prosthetic Replac   $1,850.20
22200         Osteotomy Of Spine For Correction Fixed Deformity                  $0.00
22201         Osteotomy Of Spine For Correction Fixed Deformity                  $0.00
22202         Osteotomy Of Spine For Correction Fixed Deformity                  $0.00
22203         Osteotomy Of Spine For Correction Fixed Deformity              $3,025.00
22206         Osteotomy Of Spine For Correction Fixed Deformity              $2,734.60
22207         Osteotomy Of Spine For Correction Fixed Deformity                  $0.00
22210         Osteot Spi Pst/Pstlat Appr 1 Vrt Sgm Crv                       $1,661.80
22212         Osteot Spi Pst/Pstlat Appr 1 Vrt Sgm Thrc                      $1,344.88
22214         Osteot Spi Pst/Pstlat Appr 1 Vrt Sgm Lmbr                      $1,364.62
22216         Osteot Spi Pst/Pstlat Appr 1 Vrt Sgm Ea Vrt Sgm                  $387.83
22220         Osteot Spi W/Dskc Ant Appr 1 Vrt Sgm Crv                       $1,479.41
22222         Osteot Spi W/Dskc Ant Appr 1 Vrt Sgm Thrc                      $1,377.32
22224         Osteot Spi W/Dskc Ant Appr 1 Vrt Sgm Lmbr                      $1,479.46
22226         Osteot Spi W/Dskc Ant Appr 1 Vrt Sgm Ea Vrt Sgm                  $388.36
22230         Osteotomy Of Spine For Correction Of Deformity                  $507.60
22250         Prophylactic Treatment (Plating And/Or Wiring)                     $0.00
22251         Prophylactic Treatment (Plating And/Or Wiring)                     $0.00
22305         Cltx Vrt Process Fx                                             $207.27
22310         Cltx Vrt Bdy Fx W/O Mnpj Req&W/Csting/Bracing                   $293.96
22315         Cltx Vrt Fx&/Dislc Csting/Bracing Mnpj/Trcj                     $886.88
22318         Optx&/Rdctj Odntd Fx&/Dislc Ant Fixj W/O Grfg                  $1,504.52
22319         Optx&/Rdctj Odntd Fx&/Dislc Ant W/Int Fixj Grf                 $1,672.30
22325         Optx&/Rdctj Vrt Fx&/Dislc Pst 1 Vrt Sgm Lmbr                   $1,254.02
22326         Optx&/Rdctj Vrt Fx&/Dislc Pst 1 Vrt Sgm Crv                    $1,372.60
22327         Optx&/Rdctj Vrt Fx&/Dislc Pst 1 Vrt Sgm Thrc                   $1,305.13
22328         Optx&/Rdctj Vrt Fx&/Dislc Pst 1 Vrt Sgm Ea Sgm                   $287.57
22330         Open Treatment And Fusion, Cervical Spine;                     $2,238.50
22335         Open Treatment And Fusion, Cervical Spine;                     $2,541.00
22345         Open Treatment And Fusion, Cervical Spine;                     $2,420.00
22355         Open Treatment And Fusion, Posterior Approach, With            $2,117.50
22356         Open Treatment And Fusion, Posterior Approach, With            $2,117.50
22360         Open Treatment And Fusion, Posterior Approach                  $2,420.00
22361         Open Treatment And Fusion, Posterior Approach                  $2,601.50
22370         Open Treatment And Fusion, Posterolateral Or                   $2,420.00
22371         Open Treatment And Fusion, Posterolateral Or                   $2,601.50
22379         Harrington Rod Technique                                        $302.50
22505         Mnpj Spi Req Anes Any Region                                    $117.58
22520         Prq Vrtpls 1 Vrt Bdy Uni/Bi Njx Thrc                            $539.21
22521         Prq Vrtpls 1 Vrt Bdy Uni/Bi Njx Lmbr                            $509.24
22522         Prq Vrtpls 1 Vrt Bdy Uni/Bi Njx Ea Thrc/Lmbr Vrt                $238.54
22523         Prq Vrt Agmntj Mchnl Dev 1 Vrt Bdy Thrc                         $619.29
22524         Prq Vrt Agmntj Mchnl Dev 1 Vrt Bdy Lmbr                         $593.41
22525         Prq Vrt Agmntj Mchnl Dev 1 Vrt Bdy Ea Thrc/Lmbr                 $284.29
22532         Arthrd Lat Xtrcvtry Min Dskc Ntrspc Thrc                       $1,621.35
22533         Arthrd Lat Xtrcvtry Min Dskc Ntrspc Lmbr                       $1,510.64
22534         Arthrd Lat Xtrcvtry Min Dskc Ntrspc Thrc/Lmbr Ea                $382.68

                                             Page 17
                           MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
22548         Arthrd Ant Transoral/Xtroral C1-C2 +-Exc Odntd                 $1,785.20
22550         Arthrodesis With Diskectomy, Cervical,                         $1,936.00
22552         Arthrodesis With Diskectomy, Cervical,                         $3,932.50
22554         Arthrd Ant Ntrbdy Min Dskc Ntrspc Crv Belw C2                  $1,316.13
22555         Arthrodesis With Diskectomy, Cervical, Anterior                $2,238.50
22556         Arthrd Ant Ntrbdy Min Dskc Ntrspc Thrc                         $1,596.08
22558         Arthrd Ant Ntrbdy Min Dskc Ntrspc Lmbr                         $1,470.51
22560         Arthrodesis With Diskectomy, Lumbar Or Thoracic,               $2,165.90
22561         Arthrodesis With Diskectomy, Lumbar Or Thoracic,               $2,165.90
22565         Arthrodesis With Diskectomy, Lower Lumbar Spine,               $2,117.50
22585         Arthrd Ant Ntrbdy Min Dskc Ntrspc Ea Ntrspc                     $356.37
22590         Arthrd Pst Tq Craniocrv Occiput-C2                             $1,437.18
22595         Arthrd Pst Tq Atlas-Axis C1-C2                                 $1,368.11
22600         Arthrd Pst/Pstlat Tq 1 Lvl Crv Belw C2 Sgm                     $1,150.70
22610         Arthrd Pst/Pstlat Tq 1 Lvl Thrc                                $1,141.40
22612         Arthrd Pst/Pstlat Tq 1 Lvl Lmbr                                $1,458.64
22614         Arthrd Pst/Pstlat Tq 1 Lvl Ea Vrt Sgm                            $413.65
22615         Cervical Fusion, Anterior Approach (C3-T1) With Iliac          $2,238.50
22617         Atlas-Axis Fusion (C1-C2 Or C3) With Iliac                     $2,420.00
22620         Cervicocranial Fusion (Occiput Through C2)                     $2,165.90
22625         Arthrodesis, Lateral Transverse Process Technique,             $1,920.42
22630         Arthrd Pst Ntrbdy Lam&/Dskc Ntrspc 1 Lmbr                      $1,457.77
22632         Arthrd Pst Ntrbdy Lam&/Dskc Ntrspc 1 Ea Ntrspc                  $336.76
22640         Thoracic Or Lumbar Fusion, Posterior Or Posterolateral         $1,936.00
22645         Thoracic Or Lumbar Fusion, Posterior Or Posterolateral         $2,238.50
22650         Arthrodesis, Posterior, Posterolateral Or Lateral Transverse    $550.32
22655         Thoracic Or Lumbar Fusion;                                     $2,541.00
22670         Thoracic Or Lumbar Fusion;                                     $2,541.00
22680         Thoracic Or Lumbar Fusion;                                     $3,025.00
22700         Lumbar Spine Fusion;                                           $2,238.50
22720         Lumbar Spine Fusion;                                           $3,388.00
22730         Arthrodesis, Primary Or Repair Of Pseudarthrosis;               $484.00
22735         Arthrodesis, Primary Or Repair Of Pseudarthrosis;               $605.00
22800         Arthrd Pst Spi Dfrm +-Cst Up 6 Vrt Seg                         $1,274.93
22802         Arthrd Pst Spi Dfrm +-Cst 7 12 Vrt Seg                         $2,079.36
22804         Arthrd Pst Spi Dfrm +-Cst 13/> Vrt Seg                         $2,433.69
22808         Arthrd Ant Spi Dfrm +-Cst 2-3 Vrt Seg                          $1,786.81
22810         Arthrd Ant Spi Dfrm +-Cst 4-7 Vrt Seg                          $2,016.80
22812         Arthrd Ant Spi Dfrm +-Cst 8/> Vrt Seg                          $2,176.69
22818         Kyphc Circmftl Expos Spi&Rescj Vrt Sgm 1/2 Seg                 $2,121.09
22819         Kyphc Circmftl Expos Spi&Rescj Vrt Sgm 3/> Seg                 $2,345.30
22820         Harvesting Of Bone Autograft Through Separate Incision          $303.29
22830         Expl Spi Fusion                                                 $777.53
22840         Pst Non-Sgmtl Instrmj                                           $804.89
22841         Int Spi Fixj Wirg Spinous Processes                                $0.00
22842         Pst Sgmtl Instrmj 3-6 Vrt Seg                                    $807.52
22843         Pst Sgmtl Instrmj 7-12 Vrt Seg                                  $846.88
22844         Pst Sgmtl Instrmj 13/> Vrt Seg                                 $1,052.53
22845         Ant Instrmj 2-3 Vrt Seg                                         $777.99
22846         Ant Instrmj 4-7 Vrt Seg                                         $806.33
22847         Ant Instrmj 8/> Vrt Seg                                          $888.30
22848         Pel Fixj Non-Sacrum                                             $383.64
22849         Rinsj Spi Fixj Dev                                             $1,260.24
22850         Rmvl Pst Nonsgmtl Instrmj                                       $684.76
22851         Appl Intervrt Biomchn Dev Vrt Dfct/Ntrspc                       $427.75

                                              Page 18
                           MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                     Amount
22852         Rmvl Pst Sgmtl Instrmj                                         $652.76
22855         Rmvl Ant Instrmj                                              $1,053.41
22899         Unlis Px Spi                                                      $0.00
22900         Exc Abdl Wall Tum Subfscal                                     $364.44
22910         Abdominal Fascial Transplants, Bilateral                      $1,633.50
22999         Unlis Px Abd Muscskel Sys                                         $0.00
23000         Rmvl Subdeltoid Calcareous Deps Opn                            $375.99
23020         Capsular Contrcure Rls                                         $670.07
23030         I&D Sho Area Dp Absc/Hmtma                                     $258.36
23031         I&D Sho Area Infct Bursa                                       $216.81
23035         Inc B1 Cortex Sho Area                                         $690.46
23036         Incision, Deep, With Opening Of Cortex                         $338.80
23040         Arthrt Glenohumrl Jt W/Expl Drg/Rmvl Fb                        $692.46
23042         Arthrotomy, Glenohumeral Joint, For Infection, With Explora    $968.00
23044         Arthrt Acromclav Strnclav Jt W/Expl Drg/Rmvl Fb                $550.44
23065         Bx Soft Tiss Sho Area Supfc                                    $194.28
23066         Bx Soft Tiss Sho Area Dp                                       $365.60
23075         Exc Soft Tiss Tum Sho Area Subq                                $183.24
23076         Exc Soft Tiss Tum Sho Area Dp Subfscal/Im                       $538.31
23077         Rad Rescj Tum Soft Tiss Sho Area                              $1,081.65
23100         Arthrt Glenohumrl Jt W/Bx                                      $472.43
23101         Arthrt Acromclav/Strnclav Jt W/Bx&/Exc Crtlg                    $442.64
23105         Arthrt Glenohumrl Jt W/Synvct +-Bx                              $624.08
23106         Arthrt Strnclav Jt W/Synvct +-Bx                                $473.15
23107         Arthrt Glenohumrl Jt W/Jt Expl +-Rmvl Loose/Fb                 $649.93
23110         Excision, Subacromial (Subdeltoid) Bursa                       $484.00
23120         Open Surgical Partial Removal Of Collar Bone                   $550.15
23125         Claviculectomy Tot                                             $691.11
23130         Partial Repair Or Removal Of Shoulder Bone                     $592.88
23140         Exc/Curtg B1 Cst/B9 Tum Clav/Scapula                           $494.72
23145         Exc/Curtg B1 Cst/B9 Tum Clav/Scapula W/Agrft                   $676.86
23146         Exc/Curtg B1 Cst/B9 Tum Clav/Scapula W/Algrft                  $606.87
23150         Exc/Curtg B1 Cst/B9 Tum Prox Hum                               $626.52
23155         Exc/Curtg B1 Cst/B9 Tum Prox Hum W/Agrft                        $753.63
23156         Exc/Curtg B1 Cst/B9 Tum Prox Hum W/Algrft                       $650.99
23170         Sequestrectomy Clav                                            $529.11
23171         Sequestrectomy (Eg, For Osteomyelitis Or Bone Abscess),        $484.00
23172         Sequestrectomy Scapula                                         $538.12
23173         Sequestrectomy (Eg, For Osteomyelitis Or Bone Abscess),        $484.00
23174         Sequestrectomy Humrl Head Surg Nck                             $724.24
23175         Sequestrectomy (Eg, For Osteomyelitis Or Bone Abscess),       $1,125.30
23180         Prtl Exc B1 Clav                                               $712.22
23181         Partial Excision (Craterization, Saucerization, Or             $484.00
23182         Prtl Exc B1 Scapula                                            $681.46
23183         Partial Excision (Craterization, Saucerization, Or             $484.00
23184         Prtl Exc B1 Prox Hum                                           $759.26
23185         Partial Excision (Craterization, Saucerization, Or            $1,125.30
23190         Ostectomy Scapula Prtl                                         $545.06
23195         Rescj Humrl Head                                               $716.83
23200         Rad Rescj Tum Clav                                             $850.69
23210         Rad Rescj Tum Scapula                                          $884.15
23220         Rad Rescj B1 Tum Prox Hum                                     $1,039.52
23221         Rad Rescj B1 Tum Prox Hum W/Agrft                             $1,216.91
23222         Rad Rescj B1 Tum Prox Hum W/Prostc Rplcmt                     $1,635.63
23330         Rmvl Fb Sho Subq                                               $150.33

                                              Page 19
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
23331         Rmvl Fb Sho Dp                                                  $573.18
23332         Rmvl Fb Sho Comp                                                $852.44
23350         Njx Px Sho Arthg/Enhncd Ct/Mri Sho Arthg                        $180.37
23355         Arthroscopy,Shoulder,Diag                                         $42.35
23356         Arthrscpy Shldr Srgcl;Dbrdmnt W/Crtlg Shvng&Etc                 $508.20
23357         Arthrscpy Shldr; W/Synvl Biopsy                                 $435.60
23358         Arthrscpy Shldr Surgcl; W/Rmvl Loose Body                       $399.30
23395         Musc Tr Any Typ Sho/Upr Arm 1                                  $1,205.55
23397         Musc Tr Any Typ Sho/Upr Arm Mlt                                $1,127.67
23400         Scapulopexy                                                     $969.41
23405         Tx Sho Area 1 Tdn                                                $623.06
23406         Tx Sho Area Mlt Tdn Thru Sm Inc                                  $782.07
23410         Open Repair Of Rotator Cuff, Recent                             $891.60
23412         Open Repair Of Rotator Cuff, Old                                $948.89
23415         Coracoacromial Ligm Rls +-Acromp                                $731.29
23420         Reconstruction Rotator Cuff, Old                                $980.65
23430         Tenodis Long Tdn Biceps                                         $737.18
23440         Rescj/Trnsplj Long Tdn Biceps                                   $765.30
23450         Capsl-Rhphy Ant Putti-Platt Px                                  $951.15
23455         Capsl-Rhphy Ant W/Labral Rpr                                   $1,015.87
23460         Capsl-Rhphy Ant Any Typ W/B1 Blk                               $1,094.94
23462         Capsl-Rhphy Ant Any Typ W/Coracoid Process Tr                  $1,070.38
23465         Capsl-Rhphy Glenohumrl Jt Pst +-B1 Blk                         $1,082.64
23466         Capsl-Rhphy Glenohumrl Jt Multi-Dirional Ins                   $1,039.81
23470         Arthrp Glenohumrl Jt Hemiarthrp                                $1,199.77
23472         Arthrp Glenohumrl Jt Tot Sho                                   $1,424.18
23480         Osteot Clav +-Int Fixj                                           $813.44
23485         Osteot Clav +-Int Fixj W/B1 Grf Non/Mal                          $952.92
23490         Proph Tx N/P/Pltwr +-Mma Clav                                   $818.32
23491         Proph Tx N/P/Pltwr +-Mma Prox Hum                              $1,018.62
23500         Cltx Clavicular Fx W/O Mnpj                                     $223.93
23505         Cltx Clavicular Fx W/Mnpj                                       $356.45
23510         Treatment Of Open Clavicular Fracture, With Uncomplicated So    $401.92
23515         Optx Clavicular Fx +-Int/Xtrnl Fixj                              $564.85
23520         Cltx Strnclav Dislc W/O Mnpj                                    $226.55
23525         Cltx Strnclav Dislc W/Mnpj                                      $348.05
23530         Optx Strnclav Dislc Aqt/Chrnc                                   $534.67
23532         Optx Strnclav Dislc Aqt/Chrnc W/Fscal Grf                        $606.74
23540         Cltx Acromclav Dislc W/O Mnpj                                   $250.62
23545         Cltx Acromclav Dislc W/Mnpj                                     $304.80
23550         Optx Acromclav Dislc Aqt/Chrnc                                  $548.91
23552         Optx Acromclav Dislc Aqt/Chrnc W/Fscal Grf                       $638.02
23570         Cltx Scapular Fx W/O Mnpj                                       $231.52
23575         Cltx Scapular Fx W/Mnpj +-Skel Tracj                            $387.60
23580         Treatment Of Open Scapular Fracture, With Uncomplicated Soft    $384.67
23585         Optx Scapular Fx +-Int Fixj                                      $673.14
23600         Cltx Prox Humrl Fx W/O Mnpj                                      $337.76
23605         Cltx Prox Humrl Fx W/Mnpj +-Skel Tracj                          $455.07
23610         Treatment Of Open Humeral (Surgical Or Anatomical Neck) Frac    $427.45
23615         Optx Prox Humrl Fx +-Int/Xtrnl Tubrst                            $730.36
23616         Optx Prox Humrl Fx +-Int/Xtrnl Tubrst Prostc                   $1,455.12
23620         Cltx Grter Humrl Tubrst Fx W/O Mnpj                              $295.36
23625         Cltx Grter Humrl Tubrst Fx W/Mnpj                                $403.56
23630         Optx Grter Humrl Tubrst Fx +-Int/Xtrnl Fixj                      $565.16
23650         Cltx Sho Dislc W/Mnpj W/O Anes                                  $312.52

                                            Page 20
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
23655         Cltx Sho Dislc W/Mnpj Req Anes                                  $347.80
23658         Treatment Of Open Shoulder Dislocation, With Uncomplicated S    $467.13
23660         Optx Aqt Sho Dislc                                              $561.18
23665         Cltx Sho Dislc W/Fx Humrl Tubrst W/Mnpj                         $436.10
23670         Optx Sho Dislc W/Fx Humrl Tubrst +-Int/Xtrnl                     $597.76
23675         Cltx Sho Dislc W/Surg/Antmcl Nck Fx W/Mnpj                      $542.28
23680         Optx Sho Dislc W/Surg/Antmcl Nck Fx +-Int/Xtrnl                  $738.65
23700         Mnpj W/Anes Sho Jt W/Appl Fixj Apparatus                        $195.17
23800         Arthrd Glenohumrl Jt                                           $1,006.77
23802         Arthrd Glenohumrl Jt W/Autog Grf                               $1,107.38
23810         Follow Up Family Planning Visit                                   $28.00
23900         Ntrthrc Amp                                                    $1,291.36
23920         Disrtcj Sho                                                    $1,007.62
23921         Disrtcj Sho Sec Clsr/Scar Revj                                  $431.29
23929         Unlis Px Sho                                                       $0.00
23930         I&D Upr Arm/Elbw Area Dp Absc/Hmtma                             $224.60
23931         I&D Upr Arm/Elbw Area Bursa                                     $165.74
23935         Inc Dp W/Opng B1 Cortex Hum/Elbw                                $491.96
23936         Incision, Deep, With Opening Of (Eg, Cortex For                 $338.80
24000         Arthrt Elbw W/Expl Drg/Rmvl Fb                                  $450.50
24001         Arthrotomy, Elbow, For Infection, With Exploration, Drainage    $883.30
24006         Arthrt Elbw Capsular Exc Capsular Rls Spx                       $690.31
24065         Bx Soft Tiss Upr Arm/Elbw Area Supfc                            $161.26
24066         Bx Soft Tiss Upr Arm/Elbw Area Dp                               $434.60
24075         Exc Tum Soft Tiss Upr Arm/Elbw Area Subq                        $351.56
24076         Exc Tum Soft Tiss Upr Arm/Elbw Area Dp                          $454.90
24077         Rad Rescj Tum Soft Tiss Upr Arm/Elbw Area                       $818.91
24100         Arthrt Elbw W/Synval Bx Only                                    $378.18
24101         Arthrt Elbw W/Jt Expl +-Bx +-Rmvl Loose/Fb                      $483.59
24102         Arthrt Elbw W/Synvct                                            $602.16
24105         Exc Olecrn Bursa                                                $317.27
24110         Exc/Curtg B1 Cst/B9 Tum Hum                                     $569.00
24115         Exc/Curtg B1 Cst/B9 Tum Hum W/Agrft                              $684.15
24116         Exc/Curtg B1 Cst/B9 Tum Hum W/Algrft                             $854.26
24120         Exc/Curtg B1 Cst/B9 Tum H/N Rds/Olecrn                          $505.37
24125         Exc/Curtg B1 Cst/B9 Tum H/N Rds/Olecrn W/Agrft                   $563.03
24126         Exc/Curtg B1 Cst/B9 Tum H/N Rds/Olecrn W/Algrft                 $608.78
24130         Exc Rdl Head                                                    $492.99
24134         Sequestrectomy Shft/Dstl Hum                                    $762.44
24135         Sequestrectomy (Eg, For Osteomyelitis Or Bone Abscess),         $423.50
24136         Sequestrectomy Rdl Head/Nck                                     $610.45
24137         Sequestrectomy (Eg, For Osteomyelitis Or Bone Abscess),         $508.20
24138         Sequestrectomy Olecrn Process                                   $635.21
24139         Sequestrectomy (Eg, For Osteomyelitis Or Bone Abscess),         $471.90
24140         Prtl Exc B1 Hum                                                 $749.15
24144         Partial Excision (Craterization, Saucerization Or              $1,052.70
24145         Prtl Exc B1 Rdl Head/Nck                                        $629.90
24146         Partial Excision (Craterization, Saucerization Or               $726.00
24147         Prtl Exc B1 Olecrn Process                                      $647.52
24148         Partial Excision (Craterization, Saucerization Or               $568.70
24149         Rad Rescj Capsl Tiss&Htrtpc B1 Elbw Contrct                    $1,039.29
24150         Rad Rescj Tum Shft/Dstl Hum                                     $952.25
24151         Rad Rescj Tum Shft/Dstl Hum W/Agrft                            $1,114.55
24152         Rad Rescj Tum Rdl Head/Nck                                      $720.12
24153         Rad Rescj Tum Rdl Head/Nck W/Agrft                              $674.35

                                            Page 21
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
24155         Rescj Elbw Jt Arthrectomy                                       $813.91
24160         Implt Rmvl Elbw Jt                                              $591.69
24164         Implt Rmvl Rdl Head                                             $480.02
24200         Rmvl Fb Upr Arm/Elbw Area Subq                                  $144.98
24201         Rmvl Fb Upr Arm/Elbw Area Dp                                    $404.97
24220         Njx Elbw Arthg                                                  $429.01
24300         Mnpj Elbw Under Anes                                            $363.76
24301         Musc/Tdn Tr Any Typ Upr Arm/Elbw 1                              $742.69
24305         Tdn Lngth Upr Arm/Elbw Ea Tdn                                   $569.74
24310         Tx Opn Elbw Sho Ea Tdn                                          $468.00
24320         Tenplsty W/Musc Tr +-Fr Grf Elbw Sho 1                          $725.41
24330         Flxr-Plasty Elbw                                                $704.50
24331         Flxr-Plasty Elbw W/Xtnsr Advmnt                                 $780.12
24332         Tnols Triceps                                                   $555.91
24340         Tenodis Biceps Tdn Elbw Spx                                     $599.45
24341         Rpr Tdn/Musc Upr Arm/Elbw Ea Tdn/Musc 1/2                       $630.50
24342         Rinsj Rptd Biceps/Triceps Tdn Dstl +-Tdn Grf                    $777.55
24343         Rpr Lat Coltrl Ligm Elbw W/Local Tiss                           $667.52
24344         Rcnstj Lat Coltrl Ligm Elbw W/Tdn Grf Hrvg                     $1,024.91
24345         Rpr Medial Coltrl Ligm Elbw W/Local Tiss                        $663.86
24346         Rcnstj Medial Coltrl Ligm Elbw W/Tdn Grf                       $1,019.80
24350         Fasct Lat/Medial                                                $432.62
24351         Fasct Lat/Medial W/Xtnsr Origin Dtchmnt                         $474.57
24352         Fasct Lat/Medial W/Annular Ligm Rescj                           $507.54
24354         Fasct Lat/Medial W/Stripping                                    $506.73
24356         Fasct Lat/Medial W/Prtl Ostectomy                               $521.99
24360         Arthrp Elbw W/Memb                                              $884.44
24361         Arthrp Elbw W/Dstl Humrl Prostc Rplcmt                         $1,001.83
24362         Arthrp Elbw W/Implt&Fsca Lata Ligm Rcnstj                      $1,017.42
24363         Arthrp Elbw W/Dstl Hum&Prox Ur Prostc Rplcmt                   $1,307.03
24365         Arthrp Rdl Head                                                 $626.32
24366         Arthrp Rdl Head W/Implt                                         $674.51
24400         Osteot Hum +-Int Fixj                                           $812.85
24410         Mlt Osteot W/Relignmt Imed Rod Humrl Shft                      $1,026.25
24420         Ostpl Hum                                                       $979.86
24430         Rpr Non/Mal Hum W/O Grf                                         $921.89
24435         Rpr Non/Mal Hum W/Iliac/Oth Agrft                               $976.80
24470         Hemiepiphysl Arrst                                              $664.44
24495         Dcmprn Fasct F/Arm W/Brach Art Expl                             $678.45
24498         Proph Tx N/P/Pltwr +-Mma Humrl Shft                             $864.99
24500         Cltx Humrl Shft Fx W/O Mnpj                                     $336.98
24505         Cltx Humrl Shft Fx W/Mnpj +-Skel Tracj                          $494.27
24506         Treatment Of Closed Humeral Shaft Fracture; Percutaneous Ins    $605.13
24510         Treatment Of Open Humeral Shaft Fracture, With Uncomplicated    $521.64
24515         Optx Humrl Shft Fx W/Plate/Screws +-Cerclage                    $855.47
24516         Tx Humrl Shft Fx W/Insj Imed Implt +-Cerclage                   $847.07
24530         Cltx Sprcndylr/Transcndylr Humrl Fx+-Mnpj                       $350.33
24531         Treatment Of Closed Humeral Supracondylar Or Transcondylar F    $483.00
24535         Cltx Sprcndylr/Transcndylr Humrl Fx W/Mnpj                      $609.71
24536         Treatment Of Closed Humeral Supracondylar Or Transcondylar F    $614.44
24538         Prq Skel Fixj Sprcndylr/Trnscndylr Humrl Fx                     $730.50
24540         Treatment Of Open Humeral Supracondylar Or Transcondylar Fra    $520.95
24542         Treatment Of Open Humeral Supracondylar Or Transcondylar Fra    $722.77
24545         Optx Humrl Sprcndylr/Transcndylr Fx +-Int/Xtrnl                 $769.30
24546         Optx Humrl Sprcndylr/Transcndylr Fx +-Condylar                 $1,105.11

                                           Page 22
                         MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
24560         Cltx Humrl Epcndylr Fx Medial/Lat W/O Mnpj                      $306.77
24565         Cltx Humrl Epcndylr Fx Medial/Lat W/Mnpj                        $509.28
24566         Prq Skel Fixj Humrl Epcndylr Fx Medial/Lat Mnpj                 $640.76
24570         Treatment Of Open Humeral Epicondylar Fracture, Medial Or La    $461.95
24575         Optx Humrl Epcndylr Medial/Lat +-Int/Xtrnl Fixj                 $771.17
24576         Cltx Humrl Cndylr Fx Medial/Lat W/O Mnpj                        $305.89
24577         Cltx Humrl Cndylr Fx Medial/Lat W/Mnpj                          $531.75
24578         Treatment Of Open Humeral Condylar Fracture, Medial Or Later    $569.94
24579         Optx Humrl Cndylr Fx Medial/Lat+-Int/Xtrnl Fixj                 $834.16
24580         Treatment Of Closed Comminuted Elbow Fracture (Fracture Dist    $361.56
24581         Treatment Of Closed Comminuted Elbow Fracture (Fracture Dist    $513.70
24582         Prq Skel Fixj Humrl Cndylr Fx Medial/Lat W/Mnpj                 $706.88
24583         Treatment Of Open Comminuted Elbow Fracture (Fracture Distal    $672.75
24585         Open Treatment Of Closed Or Open Comminuted Elbow Fracture (    $982.90
24586         Optx Priarticular Fx&/Dislc Elbw                               $1,077.03
24587         Optx Priarticular Fx&/Dislc Elbw W/Implt Arthrp                $1,068.68
24588         Open Treatment Of Closed Or Open Comminuted Elbow Fracture (   $1,151.95
24600         Tx Clsd Elbw Dislc W/O Anes                                     $384.97
24605         Tx Clsd Elbw Dislc Req Anes                                     $429.11
24610         Treatment Of Open Elbow Dislocation, With Uncomplicated Soft    $542.68
24615         Optx Aqt/Chrnc Elbw Dislc                                       $697.92
24620         Cltx Montgg Typ Fx Dislc Elbw W/Mnpj                            $527.71
24625         Treatment Of Open Monteggia Type Of Fracture Dislocation At     $673.09
24635         Optx Montgg Typ Fx Dislc Elbw +-Int/Xtrnl Fixj                 $1,100.97
24640         Cltx Rdl Head Sublxtj Chld Nursemaid Elbw W/Mnpj                $120.57
24650         Cltx Rdl H/N Fx W/O Mnpj                                        $260.63
24655         Cltx Rdl H/N Fx W/Mnpj                                          $439.25
24660         Treatment Of Open Radial Head Or Neck Fracture, With Uncompl    $411.24
24665         Optx Rdl H/N Fx +-Int Fixj/Rdl Head Exc                         $632.04
24666         Optx Rdl H/N Fx +-Int Fixj/Rdl Head Exc Prostc                  $712.62
24670         Cltx Ur Fx Prox End W/O Mnpj                                    $273.25
24675         Cltx Ur Fx Prox End W/Mnpj                                      $452.99
24680         Treatment Of Open Ulnar Fracture, Proximal End (Olecranon Pr    $446.08
24685         Open Repair Elbow Fracture Involving Ulnar Bone                 $663.03
24700         Manipulation Under General Anesthesia (Includes                 $859.10
24800         Arthrd Elbw Jt Local                                            $804.67
24802         Arthrd Elbw Jt W/Autog Grf                                      $980.04
24900         Amp Arm Thru Hum W/Prim Clsr                                    $684.25
24920         Amp Arm Thru Hum Opn Circular Guillotine                        $690.25
24925         Amp Arm Thru Hum Sec Clsr/Scar Revj                             $539.36
24930         Amp Arm Thru Hum Re-Amp                                         $716.79
24931         Amp Arm Thru Hum W/Implt                                        $773.81
24935         Stump Elongation Uxtr                                           $965.42
24940         Cineplasty Uxtr Compl Px                                       $1,270.50
24999         Unlis Px Hum/Elbw                                                  $0.00
25000         Inc Xtnsr Tdn Shth Wrst                                         $401.59
25001         Inc Flxr Tdn Shth Wrst                                          $297.15
25005         Tendon Sheath Incision; At Wrist For Other Stenosing Tenosyn    $320.15
25020         Dcmprn Fasct F/Arm&Wrst Flxr/Xtnsr W/O Dbrdmt                    $621.07
25023         Dcmprn Fasct F/Arm&/Wrst Flxr/Xtnsr W/Dbrdmt                   $1,121.79
25024         Dcmprn Fasct F/Arm&/Wrst Flxr&Xtnsr W/O Dbrdmt                   $689.98
25025         Dcmprn Fasct F/Arm&/Wrst Flxr&Xtnsr Dbrdmt Nv                  $1,089.01
25028         I&D F/Arm&/Wrst Dp Absc/Hmtma                                   $535.42
25031         I&D F/Arm&/Wrst Bursa                                           $479.88
25035         Inc Dp B1 Cortex F/Arm&/Wrst                                    $834.77

                                           Page 23
                           MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
25036         Incision, Deep, With Opening Of Cortex (Eg, For                 $338.80
25040         Arthrt Rdcrpl/Midcarpl Jt W/Expl Drg/Rmvl Fb                    $582.95
25041         Arthrotomy, Radiocarpal Or Mediocarpal Joint, For Infection,    $399.30
25065         Bx Soft Tiss F/Arm&/Wrst Supfc                                  $181.88
25066         Bx Soft Tiss F/Arm&/Wrst Dp                                     $442.22
25075         Exc Tum Soft Tiss F/Arm&/Wrst Area Subq                         $382.65
25076         Exc Tum Soft Tiss F/Arm&/Wrst Area Dp                           $576.65
25077         Rad Rescj Tum Soft Tiss F/Arm&/Wrst Area                        $881.19
25085         Capsul Wrst                                                     $506.55
25100         Arthrt Wrst Jt W/Bx                                             $367.21
25101         Arthrt Wrst Jt W/Jt Expl +-Bx +-Rmvl Loose/Fb                   $421.68
25105         Arthrt Wrst Jt W/Synvct                                         $529.04
25107         Arthrt Dstl Radiour Jt Rpr Triang Crtlg Cplx                    $587.10
25110         Exc Les Tdn Shth F/Arm&/Wrst                                    $434.70
25111         Exc Ganglion Wrst Dorsal/Volar Prim                             $323.33
25112         Exc Ganglion Wrst Dorsal/Volar Recrt                            $393.50
25115         Rad Exc Bursa Synva Wrst/F/Arm Tdn Shths Flxrs                  $910.77
25116         Rad Exc Bursa Synva Wrst/F/Arm Tdn Shths Xtnsrs                 $803.52
25118         Synvct Xtnsr Tdn Shth Wrst 1 Cmprt                              $404.37
25119         Synvct Xtnsr Tdn Shth Wrst 1 Rescj Dstl U                       $547.94
25120         Exc/Curtg B1 Cst/B9 Tum Rds/U                                   $721.53
25125         Exc/Curtg B1 Cst/B9 Tum Rds/U W/Agrft                           $811.34
25126         Exc/Curtg B1 Cst/B9 Tum Rds/U W/Algrft                          $816.80
25130         Exc/Curtg B1 Cst/B9 Tum Carpl B1S                               $466.30
25135         Exc/Curtg B1 Cst/B9 Tum Carpl B1S W/Agrft                       $575.39
25136         Exc/Curtg B1 Cst/B9 Tum Carpl B1S W/Algrft                      $494.95
25145         Sequestrectomy F/Arm&/Wrst                                      $733.11
25146         Sequestrectomy (Eg, For Osteomyelitis Or Bone Abscess);         $423.50
25150         Prtl Exc B1 U                                                   $618.66
25151         Prtl Exc B1 Rds                                                 $798.76
25153         Partial Excision (Craterization, Saucerization Or               $726.00
25170         Rad Rescj Tum Rds/U                                            $1,052.34
25210         Carpectomy 1 B1                                                 $509.56
25215         Carpectomy All B1S Prox Row                                     $668.90
25230         Rdl Styloidectomy Spx                                           $454.59
25240         Exc Dstl U Prtl/Compl                                           $485.34
25246         Njx Wrst Arthg                                                  $424.38
25248         Expl W/Rmvl Dp Fb F/Arm/Wrst                                    $537.51
25250         Rmvl Wrst Prosth Spx                                            $506.25
25251         Rmvl Wrst Prosth Comp W/Tot Wrst                                $699.07
25259         Mnpj Wrst Under Anes                                            $364.17
25260         Rpr Tdn/Musc Flxr F/Arm&/Wrst Prim 1 Ea Tdn/Musc                $846.05
25263         Rpr Tdn/Musc Flxr F/Arm&/Wrst Sec 1 Ea Tdn/Musc                 $841.88
25265         Rpr Tdn/Musc Flxr F/Arm&/Wrst Sec Fr Grf Ea                     $963.91
25270         Rpr Tdn/Musc Xtnsr F/Arm&/Wrst Prim 1 Ea Tdn                    $721.19
25272         Rpr Tdn/Musc Xtnsr F/Arm&/Wrst Sec 1 Ea Tdn/Musc                $791.69
25274         Rpr Tdn/Musc Xtnsr F/Arm&/Wrst Sec Fr Grf Ea Tdn                $894.04
25275         Rpr Tdn Shth Xtnsr F/Arm&/Wrst W/Fr Grf                          $645.12
25280         Lngth/Shrt Flxr/Xtnsr Tdn F/Arm&/Wrst 1 Ea Tdn                  $789.77
25290         Tx Opn Flxr/Xtnsr Tdn F/Arm&/Wrst 1 Ea Tdn                      $796.79
25295         Tnols Flxr/Xtnsr Tdn F/Arm&/Wrst 1 Ea Tdn                       $746.25
25300         Tenodis Wrst Flxrs Fngrs                                        $691.81
25301         Tenodis Wrst Xtnsrs Fngrs                                       $664.14
25310         Tdn Trnsplj/Tr Flxr/Xtnsr F/Arm&/Wrst 1 Ea Tdn                  $843.98
25312         Tdn Trnsplj/Tr Flxr/Xtnsr F/Arm&/Wrst 1/Tdn Grf                 $939.68

                                              Page 24
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
25315         Flxr Origin Slide F/Arm&/Wrst                                   $985.68
25316         Flxr Origin Slide F/Arm&/Wrst W/Tdn Tr                         $1,153.44
25317         Flexor Origin Slide For Volkmann Contracture;                   $773.33
25318         Flexor Origin Slide For Volkmann Contracture; With Tendon(S)   $1,030.85
25320         Capsl-Rhphy/Rcnstj Wrst Opn Carpl Ins                           $875.43
25330         Arthroplasty, Wrist;                                            $889.53
25331         Arthroplasty, Wrist; With Implant                              $1,222.59
25332         Arthrp Wrst +-Interpos +-Xtrnl/Int Fixj                          $827.74
25335         Ctrization Wrst U                                               $989.52
25337         Rcnstj Stablj Dstl U/Dstl Jt 2 Soft Tiss Stablj                 $847.51
25350         Osteot Rds Dstl 3Rd                                             $906.28
25355         Osteot Rds Middle/Prox 3Rd                                      $993.88
25360         Osteot U                                                         $889.20
25365         Osteot Rds&U                                                   $1,125.74
25370         Mlt Osteot W/Relignmt Imed Rod Rds/U                           $1,185.68
25375         Mlt Osteot W/Relignmt Imed Rod Rds&U                           $1,187.03
25390         Ostpl Rds/U Shrt                                                $999.57
25391         Ostpl Rds/U Lngth W/Agrft                                      $1,209.99
25392         Ostpl Rds&U Shrt                                               $1,198.19
25393         Ostpl Rds&U Lngth W/Agrft                                      $1,336.68
25394         Ostpl Carpl B1 Shrt                                             $756.87
25400         Rpr Non/Mal Rds/U W/O Grf                                      $1,046.27
25405         Rpr Non/Mal Rds/U W/Agrft                                      $1,273.76
25415         Rpr Non/Mal Rds&U W/O Grf                                      $1,203.52
25420         Rpr Non/Mal Rds&U W/Agrft                                      $1,394.56
25425         Rpr Dfct W/Agrft Rds/U                                         $1,377.71
25426         Rpr Dfct W/Agrft Rds&U                                         $1,330.77
25430         Insj Vasc Pedcl Carpl B1                                        $663.33
25431         Rpr Nonu Carpl B1 Ea B1                                         $717.26
25440         Rpr Nonu Scphd Carpl B1 +-Rdl Stylodc                           $801.86
25441         Arthrp W/Prostc Rplcmt Dstl Rds                                 $931.63
25442         Arthrp W/Prostc Rplcmt Dstl U                                   $785.66
25443         Arthrp W/Prostc Rplcmt Scphd Carpl Navclr                       $766.95
25444         Arthrp W/Prostc Rplcmt Lunate                                   $816.77
25445         Arthrp W/Prostc Rplcmt Trapezium                                $710.67
25446         Arthrp W/Prostc Rplcmt Dstl Rds&Prtl/Carpus                    $1,156.29
25447         Arthrp Interpos Intercarpl/Carp/Mtcrpl Jts                      $764.22
25449         Revj Arthrp W/Rmvl Implt Wrst Jt                               $1,012.93
25450         Epiphysl Arrst Epiphysiod/Stapling Dstl Rds/U                   $716.74
25455         Epiphysl Arrst Epiphysiod/Stapling Dstl Rds&U                   $820.18
25490         Proph Tx N/P/Pltwr +-Mma Rds                                    $926.75
25491         Proph Tx N/P/Pltwr +-Mma U                                      $980.76
25492         Proph Tx N/P/Pltwr +-Mma Rds&U                                 $1,107.90
25500         Cltx Rdl Shft Fx W/O Mnpj                                        $251.01
25505         Cltx Rdl Shft Fx W/Mnpj                                         $491.58
25510         Treatment Of Open Radial Shaft Fracture, With Uncomplicated     $454.71
25515         Optx Rdl Shft Fx +-Int/Xtrnl Fixj                                $674.98
25520         Cltx Rdl Shft Fx&Cltx Dislc Dstl Rad/Uln Jt                     $546.96
25525         Optx Rdl Shft Fx Fixj&Cltx Dislc Dstl Rad/Uln                   $901.85
25526         Optx Rdl Shft Fx Dstl Rad/Uln Jt W/Fx Rpr                      $1,068.46
25530         Cltx Ur Shft Fx W/O Mnpj                                         $242.64
25535         Cltx Ur Shft Fx W/Mnpj                                          $475.05
25540         Treatment Of Open Ulnar Shaft Fracture, With Uncomplicated S    $435.39
25545         Optx Ur Shft Fx +-Int/Xtrnl Fixj                                 $671.51
25560         Cltx Rdl&Ur Shft Fxs W/O Mnpj                                   $252.06

                                            Page 25
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
25565         Cltx Rdl&Ur Shft Fxs W/Mnpj                                     $515.67
25570         Treatment Of Open Radial And Ulnar Shaft Fractures, With Unc    $492.31
25574         Optx Rdl&Ur Shft Fxs W/Int/Xtrnl Fixj Rds/U                     $568.93
25575         Optx Rdl&Ur Shft Fxs W/Int/Xtrnl Fixj Rds&U                     $803.94
25600         Cltx Dstl Radial Fx/Epiphysl Sep W/O Mnpj                       $278.11
25605         Cltx Dstl Rdl Fx/Epiphysl Sep +-W/Mnpj                          $549.66
25610         Treatment Of Closed, Complex, Distal Radial Fracture (Eg, Co    $398.13
25611         Percutaneous Skeletal Fixation Of Distal Radial Fracture (Eg    $665.45
25615         Treatment Of Open Distal Radial Fracture (Eg, Colles Or Smit    $444.36
25620         Open Treatment Of Distal Radial Fracture (Eg, Colles Or Smit    $642.08
25622         Cltx Carpl Scphd Navclr Fx W/O Mnpj                             $283.16
25624         Cltx Carpl Scphd Navclr Fx W/Mnpj                               $453.76
25626         Treatment Of Open Carpal Scaphoid (Navicular) Fracture, With    $425.04
25628         Optx Carpl Scphd Navclr Fx +-Int/Xtrnl Fixj                     $655.33
25630         Cltx Carpl B1 Fx W/O Mnpj Ea B1                                 $292.72
25635         Cltx Carpl B1 Fx W/Mnpj Ea B1                                   $429.15
25640         Treatment Of Open Carpal Bone Fracture (Excluding Carpal Sca    $424.35
25645         Optx Carpl B1 Fx Ea B1                                          $563.85
25650         Cltx Ur Styloid Fx                                              $308.57
25651         Prq Skel Fixj Ur Styloid Fx                                     $431.98
25652         Optx Ur Styloid Fx                                              $583.58
25660         Cltx Rdcrpl/Intercarpl Dislc 1+ B1S W/Mnpj                      $376.41
25665         Treatment Of Open Radiocarpal Or Intercarpal Dislocation, On    $442.29
25670         Optx Rdcrpl/Intercarpl Dislc 1+ B1S                             $606.37
25671         Prq Skel Fixj Dstl Radiour Dislc                                $481.90
25675         Cltx Dstl Radiour Dislc W/Mnpj                                  $439.06
25676         Optx Dstl Radiour Dislc Aqt/Chrnc                               $621.24
25680         Cltx Trans-Scaphoprilunar Typ Fx Dislc W/Mnpj                   $426.84
25685         Optx Trans-Scaphoprilunar Typ Fx Dislc                          $713.62
25690         Cltx Lunate Dislc W/Mnpj                                        $440.06
25695         Optx Lunate Dislc                                               $626.07
25700         Manipulation Of Joint Under General Anesthesia                  $205.70
25800         Arthrd Wrst Compl W/O B1 Grf                                    $760.23
25805         Arthrd Wrst W/Sliding Grf                                       $868.41
25810         Arthrd Wrst W/Iliac/Oth Agrft                                   $821.84
25815         Arthrodesis, Intercarpal                                        $907.50
25820         Arthrd Wrst Lmtd W/O B1 Grf                                     $612.75
25825         Arthrd Wrst W/Agrft                                             $741.43
25830         Arthrd Dstl Rad/Uln Jt Sgmtl Rescj U +-B1 Grf                   $973.55
25900         Amp F/Arm Thru Rds&U                                            $859.63
25905         Amp F/Arm Thru Rds&U Opn Circular Guillotine                    $860.37
25907         Amp F/Arm Thru Rds&U Sec Clsr/Scar Revj                         $786.37
25909         Amp F/Arm Thru Rds&U Re-Amp                                     $852.61
25915         Krukenberg Px                                                  $1,467.46
25920         Disrtcj Thru Wrst                                               $667.94
25922         Disrtcj Thru Wrst Sec Clsr/Scar Revj                            $586.99
25924         Disrtcj Thru Wrst Re-Amp                                        $668.16
25927         Transmtcrpl Amp                                                 $821.92
25929         Transmtcrpl Amp Sec Clsr/Scar Revj                              $547.85
25931         Transmtcrpl Amp Re-Amp                                          $774.75
25999         Unlis F/Arm/Wrst                                                   $0.00
26010         Drg Fngr Absc Smpl                                              $271.46
26011         Drg Fngr Absc Comp                                              $425.54
26020         Drg Tdn Shth Dgt&/Palm Ea                                       $406.28
26025         Drg Plmr Bursa 1 Bursa                                          $404.62

                                            Page 26
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                            Amount
26030         Drg Plmr Bursa Mlt Bursa                              $475.54
26032         Drainage Of Palmar Bursa;                             $459.80
26034         Inc B1 Cortex Hand/Fngr                               $499.86
26035         Dcmprn Fngrs&/Hand Njx Inj                            $705.43
26037         Dcmprive Fasct Hand                                   $554.06
26040         Fasct Plmr Prq                                        $292.01
26045         Fasct Plmr Opn Prtl                                    $446.47
26055         Tdn Shth Inc                                          $648.88
26060         Tx Prq 1 Ea Dgt                                       $247.99
26070         Arthrt Expl Drg/Rmvl Loose/Fb Carp/Mtcrpl Jt          $277.19
26075         Arthrt Expl Drg/Rmvl Loose/Fb Mtcarphlngl Jt Ea       $297.97
26080         Arthrt Expl Drg/Rmvl Loose/Fb Iphal Jt Ea             $358.12
26100         Arthrt Bx Carp/Mtcrpl Jt Ea                            $308.35
26105         Arthrt Bx Mtcarphlngl Jt Ea                           $312.40
26110         Arthrt Bx Iphal Jt Ea                                  $298.33
26115         Exc Tum/Vasc Malfrmj Soft Tiss Hand/Fngr Subq         $654.11
26116         Exc Tum/Vasc Malfrmj Soft Tiss Hand/Fngr Dp           $456.06
26117         Rad Rescj Tum Soft Tiss Hand/Fngr                     $625.22
26120         Fasciectomy, Palmar, Simple, For Dupuytren's          $496.10
26121         Fasct Palm +-Z-Plasty Tiss Reargmt/Skn Grf             $579.10
26122         Fasciectomy, Palmar, Simple, For Dupuytren's          $810.70
26123         Fasct Prtl Plmr 1 Dgt Prox Iphal Jt +-Tiss             $723.02
26124         Fasciectomy, Palmar, Complicated, Requiring Skin     $1,210.00
26125         Fasct Prtl Plmr 1 Dgt Prox Iphal Jt +-Z-Plasty         $289.66
26126         Fasciectomy, Palmar, Complicated, Requiring Skin      $242.00
26128         Fasciectomy, Palmar, Complicated, Requiring Skin     $1,294.70
26130         Synvct Carp/Mtcrpl Jt                                 $427.27
26135         Synvct Mtcarphlngl Jt W/Intrnsc Rls&Xtnsr Hood        $535.56
26140         Synvct Prox Iphal Jt W/Xtnsr Rcnstj Ea Iphal Jt        $485.44
26145         Synvct Tdn Shth Rad Flxr Tdn Palm&/Fngr Ea Tdn        $491.81
26160         Exc Les Tdn Shth/Jt Capsl Hand/Fngr                   $600.13
26170         Exc Tdn Palm Flexor Or Extensor Ea                    $385.23
26180         Exc Tdn Finger Flexor Or Extensor Ea                  $419.73
26185         Sesmdc Thmb/Fngr Spx                                  $444.42
26200         Exc/Curtg B1 Cst/B9 Tum Mtcrpl                        $433.53
26205         Exc/Curtg B1 Cst/B9 Tum Mtcrpl W/Agrft                 $583.70
26206         Excision Or Curettage Of Bone Cyst Or Benign          $605.00
26210         Exc/Curtg B1 Cst/B9 Tum Phalanx Fngr                  $418.98
26215         Exc/Curtg B1 Cst/B9 Tum Phalanx Fngr W/Agrft           $531.16
26216         Excision Or Curettage Of Bone Cyst Or Benign Tumor    $399.30
26230         Prtl Exc B1 Mtcrpl                                    $490.70
26235         Prtl Exc B1 Prox/Middle Phalanx Fngr                  $478.97
26236         Prtl Exc B1 Dstl Phalanx Fngr                         $423.62
26250         Rad Rescj Mtcrpl                                      $559.67
26255         Rad Rescj Mtcrpl W/Agrft                              $856.47
26260         Rad Rescj Prox/Middle Phalanx Fngr                    $527.01
26261         Rad Rescj Prox/Middle Phalanx Fngr W/Agrft            $607.62
26262         Rad Rescj Dstl Phalanx Fngr                           $438.69
26320         Rmvl Implt From Fngr/Hand                             $327.43
26340         Mnpj Fngr Jt Under Anes Ea Jt                         $281.08
26350         Rpr/Advmnt Flxr Tdn N/Z/2 1/2 W/O Fr Grf Ea Tdn        $824.72
26352         Rpr/Advmnt Flxr Tdn N/Z/2 2W/Fr Grf Ea Tdn             $919.14
26356         Rpr/Advmnt Flxr Tdn Zone 2 1W/O Fr Grf Ea Tdn        $1,039.89
26357         Rpr/Advmnt Flxr Tdn Zone 2 2W/O Fr Grf Ea Tdn          $973.65
26358         Rpr/Advmnt Flxr Tdn Zone 2 2W/Fr Grf Ea Tdn          $1,029.86

                                            Page 27
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
26370         Rpr/Advmnt Tdn W/Ntc Supfcis Tdn Prim Ea Tdn                    $891.89
26372         Rpr/Advmnt Tdn W/Ntc Supfcis Tdn 2 W/Fr Grf Ea                 $1,011.25
26373         Rpr/Advmnt Tdn W/Ntc Supfcis Tdn 2 W/O Fr Grf Ea                $968.35
26390         Exc Flxr Tdn W/Impltj Synth Rod Dlyd Tdn Grf H/F                $904.37
26392         Rmvl Synth Rod&Insj Flxr Tdn Grf H/F Ea Rod                    $1,089.07
26410         Rpr Xtnsr Tdn Hand 1/2 W/O Fr Grf Ea Tdn                        $660.32
26412         Rpr Xtnsr Tdn Hand 1/2 W/Fr Grf Ea Tdn                          $782.60
26415         Exc Xtnsr Tdn W/Impltj Synth Rod Dlyd Grf H/F Ea                $797.29
26416         Rmvl Synth Rod&Insj Xtnsr Tdn Grf H/F Ea Rod                    $963.90
26418         Rpr Xtnsr Tdn Fngr 1/2 W/O Fr Grf Ea Tdn                        $655.61
26420         Rpr Xtnsr Tdn Fngr 1/2 W/Fr Grf Ea Tdn                          $813.82
26426         Rpr Xtnsr Tdn Ctr Slip 2 Tiss W/Lat Band Ea Fngr                $770.29
26428         Rpr Xtnsr Tdn Ctr Slip Sec W/Fr Grf Ea Fngr                     $842.34
26432         Cltx Dstl Xtnsr Tdn Insj +-Prq Pinning                          $563.68
26433         Rpr Xtnsr Tdn Dstl Insj 1/2 W/O Grf                             $612.75
26434         Rpr Xtnsr Tdn Dstl Insj 1/2 W/Fr Grf                            $702.39
26437         Relignmt Xtnsr Tdn Hand Ea Tdn                                  $690.61
26440         Tnols Flxr Tdn Palm/Fngr Ea Tdn                                 $735.38
26442         Tnols Flxr Tdn Palm&Fngr Ea Tdn                                 $956.82
26445         Tnols Xtnsr Tdn Hand/Fngr Ea Tdn                                $695.67
26449         Tnols Cplx Xtnsr Tdn Fngr W/F/Arm Ea Tdn                        $900.59
26450         Tx Flxr Palm Opn Ea Tdn                                         $435.83
26455         Tx Flxr Fngr Opn Ea Tdn                                         $432.60
26460         Tx Xtnsr Hand/Fngr Opn Ea Tdn                                   $417.68
26471         Tenodis Prox Iphal Jt Ea Jt                                     $674.80
26474         Tenodis Dstl Jt Ea Jt                                           $664.39
26476         Lngth Tdn Xtnsr Hand/Fngr Ea Tdn                                $638.74
26477         Shrt Tdn Xtnsr Hand/Fngr Ea Tdn                                 $642.61
26478         Lngth Tdn Flxr Hand/Fngr Ea Tdn                                 $700.99
26479         Shrt Tdn Flxr Hand/Fngr Ea Tdn                                  $692.50
26480         Tr/Trnspl Tdn Carp/Mtcrpl Hand W/O Fr Grf Ea Tdn                $863.09
26483         Tr/Trnspl Tdn Carp/Mtcrpl And W/Fr Tdn Grf Ea                   $948.26
26485         Tr/Trnspl Tdn Plmr W/O Fr Tdn Grf Ea Tdn                        $917.73
26489         Tr/Trnspl Tdn Plmr W/Fr Tdn Grf Ea Tdn                          $862.13
26490         Opponensplasty Supfcis Tdn Tr Typ Ea Tdn                        $845.87
26492         Opponensplasty Tdn Tr W/Grf Ea Tdn                              $927.55
26494         Opponensplasty Hypothenar Musc Tr                               $868.21
26496         Opponensplasty Oth Meths                                        $912.06
26497         Tr Tdn Restore Intrnsc Funcj Ring&Sm Fngr                       $924.09
26498         Tr Tdn Restore Intrnsc Funcj All 4 Fngrs                       $1,211.78
26499         Corrj Claw Fngr Oth Meths                                       $873.87
26500         Rcnstj Tdn Pulley Ea Tdn W/Local Tiss Spx                       $697.29
26502         Rcnstj Tdn Pulley Ea Tdn W/Tdn/Fscal Grf Spx                    $768.32
26504         Reconstruction Of Tendon Pulley, Each Tendon; With Tendon Pr    $794.71
26508         Rls Thenar Musc                                                 $703.67
26510         Cross Intrnsc Tr Ea Tdn                                         $667.89
26516         Capsld Mtcarphlngl Jt 1 Dgt                                     $772.88
26517         Capsld Mtcarphlngl Jt 2 Dgts                                    $886.29
26518         Capsld Mtcarphlngl Jt 3/4 Dgts                                  $894.58
26520         Capslctomy/Capsul Mtcarphlngl Jt Ea Jt                          $763.49
26525         Capslctomy/Capsul Iphal Jt Ea Jt                                $769.44
26527         Arthroplasty, Carpometacarpal Joint                             $776.44
26530         Arthrp Mtcarphlngl Jt Ea Jt                                     $511.57
26531         Arthrp Mtcarphlngl Jt W/Prostc Implt Ea Jt                      $599.86
26535         Arthrp Iphal Jt Ea Jt                                           $362.58

                                            Page 28
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
26536         Arthrp Iphal Jt W/Prostc Implt Ea Jt                            $632.20
26540         Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt                            $730.56
26541         Rcnstj Coltrl Ligm Mtcarphlngl 1 W/Tdn/Fscal Grf                $881.43
26542         Rcnstj Coltrl Ligm Mtcarphlngl 1 W/Local Tiss                   $747.94
26545         Rcnstj Coltrl Ligm Iphal Jt 1 W/Grf Ea Jt                       $763.70
26546         Rpr Non-Union Mtcrpl/Phalanx                                    $943.48
26548         Rpr&Rcnstj Fngr Volar Plate Iphal Jt                            $836.42
26550         Pollicization Dgt                                              $1,543.37
26551         Tr Toe-To-Hand W/Mvasc Anast Grt Toe Wrp/Arnd                  $3,289.84
26552         Reconstruction Thumb With Toe                                      $0.00
26553         Tr Toe-To-Hand W/Mvasc Anast Oth/Thn Grt Toe 1                 $2,670.56
26554         Tr Toe-To-Hand W/Mvasc Anast Oth/Thn Grt Toe 2                 $3,817.97
26555         Tr Fngr Axh Pos W/O Mvasc Anast                                $1,406.52
26556         Tr Fr Toe Jt W/Mvasc Anast                                     $3,348.96
26557         Toe To Finger Transfer; First Stage                                $0.00
26558         Toe To Finger Transfer; Each Delay                                 $0.00
26559         Toe To Finger Transfer; Second Stage                               $0.00
26560         Rpr Syndactyly Web Fngr Ea Space W/Skn Flaps                    $605.19
26561         Rpr Syndactyly Web Fngr Ea Space W/Skn Flaps&Grf                $912.91
26562         Rpr Syndactyly Web Fngr Ea Space Cplx                          $1,249.65
26565         Osteot Mtcrpl Ea                                                $747.37
26567         Osteot Phalanx Fngr Ea                                          $747.81
26568         Ostpl Lngth Mtcrpl/Phalanx                                      $980.32
26570         Bone Graft, (Includes Obtaining Graft)                          $605.00
26574         Bone Graft, (Includes Obtaining Graft)                          $605.00
26580         Rpr Cl Hand                                                    $1,259.80
26585         Repr Bifid Digit                                               $1,118.22
26587         Rcnstj Polydactylous Dgt Soft Tiss&B1                           $909.26
26590         Rpr Macrodactylia Ea Dgt                                       $1,260.00
26591         Rpr Intrnsc Musc Hand Ea Musc                                   $520.89
26593         Rls Intrnsc Musc Hand Ea Musc                                   $649.52
26596         Exc Constricting Ring Fngr W/Mlt Z-Plasties                     $705.54
26597         Release Contract W/Gft Hand/Finger                              $935.03
26600         Cltx Mtcrpl Fx 1 W/O Mnpj Ea B1                                 $234.38
26605         Cltx Mtcrpl Fx 1 W/Mnpj Ea B1                                   $316.84
26607         Cltx Mtcrpl Fx W/Mnpj W/Xtrnl Fixj Ea B1                        $465.82
26608         Prq Skel Fixj Mtcrpl Fx Ea B1                                   $467.45
26610         Treatment Of Open Metacarpal Fracture, Single, With Uncompli    $216.31
26615         Optx Mtcrpl Fx 1 +-Int/Xtrnl Fixj Ea B1                         $434.75
26641         Cltx Carp/Mtcrpl Dislc Thmb W/Mnpj                              $364.68
26645         Cltx Carp/Mtcrpl Fx Dislc Thmb W/Mnpj                           $413.49
26650         Prq Skel Fixj Carp/Mtcrpl Fx Dislc Thmb W/Mnpj                  $497.89
26655         Treatment Of Open Carpometacarpal Fracture Dislocation, Thum    $406.75
26660         Treatment Of Open Carpometacarpal Fracture Dislocation, Thum    $507.49
26665         Optx Carp/Mtcrpl Fx Dislc Thmb +-Int/Xtrnl Fixj                 $579.32
26670         Cltx Carp/Mtcrpl Dislc Thmb Mnpj Ea W/O Anes                    $333.46
26675         Cltx Carp/Mtcrpl Dislc Thmb Mnpj Ea Jt Req Anes                 $428.04
26676         Prq Skel Fixj Carp/Mtcrpl Dislc Thmb Mnpj Ea Jt                 $491.11
26680         Treatment Of Open Carpometacarpal Dislocation, Other Than Be    $406.41
26685         Optx Carp/Mtcrpl Dislc Thmb +-Int/Xtrnl Fixj Ea                 $535.63
26686         Optx Carp/Mtcrpl Dislc Thmb Cplx Mlt/Dlyd Rdctj                 $604.48
26700         Cltx Mtcarphlngl Dislc 1 W/Mnpj W/O Anes                        $324.29
26705         Cltx Mtcarphlngl Dislc 1 W/Mnpj Req Anes                        $400.68
26706         Prq Skel Fixj Mtcarphlngl Dislc 1 W/Mnpj                        $408.00
26710         Treatment Of Open Metacarpophalangeal Dislocation, Single, W    $335.68

                                            Page 29
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
26715         Optx Mtcarphlngl Dislc 1 +-Int/Xtrnl Fixj                       $459.08
26720         Cltx Phlngl Fx Prox/Middle Px/F/T W/O Mnpj Ea                   $213.79
26725         Cltx Phlngl Fx Prox/Middle Px/F/T W/Mnpj Ea                     $367.88
26727         Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T                 $462.38
26730         Treatment Of Open Phalangeal Shaft Fracture, Proximal Or Mid    $246.33
26735         Optx Phlngl Shft Fx Prox/Middle Px/F/T Fixj Ea                  $474.74
26740         Cltx Articular Fx Invg Mtcarphlngl/Iphal Jt W/O                 $214.23
26742         Cltx Articular Fx Invg Mtcarphlngl/Iphal Jt W/                  $379.55
26743         Treatment Of Closed Articular Fracture, Involving               $508.20
26744         Treatment Of Open Articular Fracture, Involving Metacarpopha    $290.49
26746         Optx Articular Fx Invg Mtcarphlngl/Iphal Jt                     $468.59
26750         Cltx Dstl Phlngl Fx Fngr/Thmb W/O Mnpj Ea                       $187.49
26755         Cltx Dstl Phlngl Fx Fngr/Thmb W/Mnpj Ea                         $309.70
26756         Prq Skel Fixj Dstl Phlngl Fx Fngr/Thmb Ea                       $411.77
26760         Treatment Of Open Distal Phalangeal Fracture, Finger Or Thum    $199.75
26765         Optx Dstl Phlngl Fx Fngr/Thmb +-Int/Xtrnl Fixj                  $355.10
26770         Cltx Iphal Jt Dislc 1 W/Mnpj W/O Anes                           $286.86
26775         Cltx Iphal Jt Dislc 1 W/Mnpj Req Anes                           $372.93
26776         Prq Skel Fixj Iphal Jt Dislc 1 W/Mnpj                           $436.54
26780         Treatment Of Open Interphalangeal Joint Dislocation, Single,    $227.35
26785         Optx Iphal Jt Dislc +-Int/Xtrnl Fixj 1                          $358.91
26820         Fusion Oppos Thmb W/Autog Grf                                   $860.28
26841         Arthrd Carp/Mtcrpl Jt Thmb +-Int Fixj                           $807.52
26842         Arthrd Carp/Mtcrpl Jt Thmb +-Int Fixj W/Agrft                   $862.05
26843         Arthrd Carp/Mtcrpl Jt Dgt Thmb Ea                               $795.22
26844         Arthrd Carp/Mtcrpl Jt Dgt Thmb Ea W/Agrft                       $880.06
26850         Arthrd Mtcarphlngl Jt +-Int Fixj                                $762.06
26852         Arthrd Mtcarphlngl Jt +-Int Fixj W/Agrft                        $851.02
26860         Arthrd Iphal Jt +-Int Fixj                                      $625.80
26861         Arthrd Iphal Jt +-Int Fixj Ea Iphal Jt                          $109.92
26862         Arthrd Iphal Jt +-Int Fixj W/Agrft                              $785.56
26863         Arthrd Iphal Jt +-Int Fixj W/Agrft Ea Jt                        $247.89
26910         Amp Mtcrpl W/Fngr/Thmb 1 +-Inteross Tr                          $754.99
26951         Amp F/Th 1/2 Jt/Phalanx 1 W/Neurect W/Dir Clsr                  $586.48
26952         Amp F/Th 1/2 Jt/Phalanx 1 W/Neurect Local Flap                  $718.04
26989         Unlis Px Hands/Fngrs                                               $0.00
26990         I&D Pelvis/Hip Jt Area Dp Absc/Hmtma                            $602.70
26991         I&D Pelvis/Hip Jt Area Infct Bursa                              $563.73
26992         Inc B1 Cortex Pelvis&/Hip Jt                                    $967.82
26995         Incision, Deep, With Opening Of Bone Cortex (Eg, For            $338.80
27000         Tx Adduxor Hip Prq Spx                                          $440.07
27001         Tx Adduxor Hip Opn                                              $530.12
27002         Tenotomy, Adductor Of Hip, Subcutaneous, Open                   $242.00
27003         Tx Adduxor Subq Opn W/Obturator Neurectomy                      $558.44
27004         Tenotomy, Adductor, Subcutaneous, Open,                         $617.10
27005         Tx Hip Flxr Opn Spx                                             $713.70
27006         Tx Abduxors&/Xtnsr Hip Opn Spx                                  $717.93
27010         Gluteal-Iliotibial Fasciotomy (Ober Type Procedure)             $484.00
27015         Iliac Crest Fasciotomy (Soutter Or Campbell Type Procedure),    $641.30
27025         Fasct Hip/Thi Any Typ                                           $797.53
27026         Ober-Yount Fasciotomy, Combined With Spica Cast,                $810.70
27030         Arthrt Hip W/Drg                                                $926.48
27031         Arthrotomy, Hip, For Infection, With Drainage;                 $1,210.00
27033         Arthrt Hip W/Expl/Rmvl Loose/Fb                                 $953.78
27035         Dnrvtj Hip Jt Intrapel/Xtrpel Intra-Artclr Brnch               $1,155.71

                                            Page 30
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
27036         Capslctomy/Capsul Hip W/Rls Hip Flxr Musc                       $934.73
27040         Bx Soft Tiss Pelvis&Hip Area Supfc                               $213.00
27041         Bx Soft Tiss Pelvis&Hip Area Dp Subfscal/Im                      $664.30
27047         Exc Tum Pelvis&Hip Area Subq Tiss                               $555.63
27048         Exc Tum Pelvis&Hip Area Dp Subfscal Im                          $452.84
27049         Rad Rescj Tum Soft Tiss Pelvis&Hip Area                         $909.53
27050         Arthrt W/Bx Si Jt                                                $352.06
27052         Arthrt W/Bx Hip Jt                                               $489.24
27054         Arthrt W/Synvct Hip Jt                                           $644.63
27060         Exc Ischial Bursa                                                $408.41
27062         Exc Trchntric Bursa/Calcification                               $426.96
27065         Exc B1 Cst/B9 Tum Supfc +-Agrft                                  $459.66
27066         Exc B1 Cst/B9 Tum Dp +-Agrft                                     $765.29
27067         Exc B1 Cst/B9 Tum W/Agrft Req Sep Inc                          $1,000.89
27070         Prtl Exc Cratrztj Saucrztj Supfc                                 $823.38
27071         Prtl Exc Cratrztj Saucrztj Dp                                    $893.76
27075         Rad Rescj Tum/Infctj Wing Ilium 1 Pubic/Ischial                $2,132.65
27076         Rad Rescj Tum/Infctj Ilium Acetabulum Bth Pubic                $1,505.26
27077         Rad Rescj Tum/Infctj Innominate B1 Tot                         $2,491.05
27078         Rad Rescj Tum/Infctj Ischial Tubrst&Grt Trchntr                  $963.73
27079         Rad Rescj Tum/Infctj Ischial Tubrst&Trchntr Fem                  $972.25
27080         Coccygectomy Prim                                                $462.78
27086         Rmvl Fb Pelvis/Hip Subq Tiss                                    $151.76
27087         Rmvl Fb Pelvis/Hip Dp                                           $616.82
27090         Rmvl Hip Prosth Spx                                              $807.53
27091         Rmvl Hip Prosth Comp W/Tot Hip Prosth Mma                      $1,484.26
27093         Njx Px Hip Arthg W/O Anes                                        $498.88
27095         Njx Px Hip Arthg Anes                                            $453.80
27096         Injection Of Joint Of Lower Back Into Pelvis                     $397.77
27097         Rls/Recession Hamstring Prox                                    $624.28
27098         Tr Adduxor Ischium                                               $649.63
27100         Tr Xtrnl Oblq Musc Trchntr W/Fscal/Tdn Xtn Grf                   $808.65
27105         Tr Paraspi Musc Hip Fasc/Tdn Xtn Grf                             $856.06
27110         Tr Iliopsoas Grter Trchntr Femur                                 $902.60
27111         Tr Iliopsoas Fem Nck                                             $860.97
27115         Muscle Release, Complete (Hanging Hip Operation)               $1,633.50
27120         Acetabuloplasty                                                $1,220.08
27122         Acetabuloplasty Rescj Fem Head                                 $1,059.11
27125         Hemiarthrp Hip Prtl                                            $1,031.32
27126         Partial Hip Replacement (Hemiarthroplasty); Cup                $1,714.70
27127         Partial Hip Replacement (Hemiarthroplasty); Cup With Acetabu   $2,095.00
27130         Arthrp Acetblr/Prox Fem Prostc Agrft/Algrft                    $1,370.86
27132         Conv Previous Hip Tot Hip Arthrp +-Agrft/Algrft                $1,594.05
27134         Revj Tot Hip Arthrp Bth +-Agrft/Algrft                         $1,904.28
27135         Secondary Reconstruction Or Revision Of                        $3,146.00
27137         Revj Tot Hip Arthrp Actblr Only +-Agrft/Algrft                 $1,439.66
27138         Revj Tot Hip Arthrp Fem Only +-Algrft                          $1,500.71
27140         Osteot&Tr Grter Trchntr Femur Spx                                $881.68
27146         Osteot Iliac Actblr/Innominate B1                              $1,209.23
27147         Osteot Iliac Actblr/Innominate B1 Opn Rdctj Hip                $1,382.60
27151         Osteot Iliac Actblr/Innominate B1 Fem Osteot                   $1,292.16
27156         Osteot Iliac Actblr/Innominate B1 Osteot Rdctj                 $1,676.96
27157         Acetabular Augmentation (Wilson Procedure)                     $1,137.40
27158         Osteot Pelvis Bi                                               $1,274.15
27161         Osteot Fem Nck Spx                                             $1,178.22

                                             Page 31
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
27165         Osteot Intertrchntric/Subtrchntric W/Int/Xtrnl                 $1,260.14
27170         B1 Grf Fem H/N Intertrchntric/Subtrchntric Area                $1,119.74
27175         Tx Slp Fem Epiphysis Trcj W/O Rdctj                             $614.38
27176         Tx Slp Fem Epiphysis 1/Mlt Pinning Situ                         $859.70
27177         Optx Slp Fem Epiphysis 1/Mlt Pinning/B1 Grf                    $1,061.14
27178         Optx Slp Fem Epiphysis Clsd Mnpj 1/Mlt Pinning                  $836.28
27179         Optx Slp Fem Epiphysis Ostpl Fem Nck Heyman Px                  $936.48
27181         Optx Slp Fem Epiphysis Osteot&Int Fixj                         $1,003.47
27185         Epiphysl Arrst Epiphysiod/Stapling Trchntr Femur                $682.66
27187         Proph Tx N/P/Pltwr +-Mma Fem Nck&Prox Femur                     $974.80
27190         Treatment Of Closed Sacral Fracture                             $178.36
27192         Open Treatment Of Closed Or Open Sacral Fracture                $919.08
27193         Cltx Pel Ring Fx Dislc Diast/Sublxtj W/O Mnpj                   $504.33
27194         Cltx Pel Ring Fx Dislc Diast/Sublxtj W/Mnpj Anes                $744.16
27195         Treatment Of Sacroiliac And/Or Symphysis Pubis Dislocation,     $205.62
27196         Treatment Of Sacroiliac And/Or Symphysis Pubis Dislocation,     $645.84
27200         Cltx Coccygeal Fx                                               $190.70
27201         Treatment Of Open Coccygeal Fracture                            $420.90
27202         Optx Coccygeal Fx                                               $940.77
27210         Treatment Of Closed Iliac, Pubic Or Ischial Fracture            $349.48
27212         Treatment Of Open Iliac, Pubic Or Ischial Fracture, With Unc    $664.81
27214         Open Treatment Of Closed Or Open Iliac, Pubic Or Ischial Fra   $1,077.09
27215         Optx Iliac Spi Tubrst Avlsn/Iliac Wing Fx W/Int                 $703.46
27216         Prq Skel Fixj Pst Pel Ring Fx&/Dislc                           $1,026.75
27217         Optx Ant Ring Fx&/Dislc W/Int Fixj                              $992.36
27218         Optx Pst Ring Fx&/Dislc W/Int Fixj                             $1,311.16
27220         Cltx Acetabulum Hip/Sockt Fx W/O Mnpj                           $530.09
27222         Cltx Acetabulum Hip/Sockt Fx Mnpj +-Skel Tracj                  $920.90
27224         Open Treatment Of Closed Or Open Acetabulum (Hip Socket) Fra   $1,199.22
27225         Open Treatment Of Closed Or Open Acetabulum (Hip Socket) Fra   $1,535.25
27226         Optx Pst/Ant Actblr Wall Fx W/Int Fixj                           $946.90
27227         Optx Actblr Fx Invg Ant/Pst 1 Column/Fx W/Int                  $1,593.72
27228         Optx Actblr Fx Invg Ant&Pst 2 Columns Fx W/Int                 $1,839.35
27230         Cltx Fem Fx Prox End Nck W/O Mnpj                               $478.52
27232         Cltx Fem Fx Prox End Nck W/Mnpj +-Skel Tracj                    $731.42
27234         Treatment Of Open Femoral Fracture, Proximal End, Neck, With   $1,086.75
27235         Prq Skel Fixj Fem Fx Prox End Nck                               $880.00
27236         Optx Fem Fx Prox End Nck Int Fixj/Prostc Rplcmt                $1,087.87
27238         Cltx Inter/Peri/Subtrochanteric Fem Fx W/O Mnpj                 $429.04
27240         Cltx Intr/Peri/Sbtrchntc Fem Fx W/Mnpj                          $891.15
27242         Treatment Of Open Intertrochanteric, Pertrochanteric, Or Sub   $1,135.74
27244         Tx Inter/Pr/Subtrchntric Fem Fx Screw Implt                    $1,115.06
27245         Tx Inter/Pr/Subtrchntric Fem Fx Imed Impltscrew                $1,397.47
27246         Cltx Grter Trchntric Fx W/O Mnpj                                $414.72
27248         Optx Grter Trchntric Fx +-Int/Xtrnl Fixj                        $759.72
27250         Cltx Hip Dislc Traumtc W/O Anes                                 $466.67
27252         Cltx Hip Dislc Traumtc Req Anes                                 $724.19
27253         Optx Hip Dislc Traumtc W/O Int Fixj                             $925.31
27254         Optx Hip Dislc Traumtc W/Actblr Wall&Fem Head Fx               $1,243.67
27255         Open Treatment Of Closed Or Open Hip Dislocation, Traumatic,   $1,444.86
27256         Tx Spon Hip Dislc Abdct Splnt/Trcj W/O Anes                     $302.72
27257         Tx Spon Hip Dislc Abdct Splnt/Trcj W/Mnpj Anes                  $327.37
27258         Optx Spon Hip Dislc Rplcmt Fem Head Actblm                     $1,074.69
27259         Optx Spon Hip Dislc Rplcmt Fem Head Actblm Shrt                $1,467.49
27265         Cltx Post Hip Arthrp Dislc W/O Anes                             $393.74

                                           Page 32
                           MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
27266         Cltx Post Hip Arthrp Dislc Req Anes                             $559.11
27275         Mnpj Hip Jt Req General Anes                                    $177.59
27280         Arthrd Si Jt W/Obtg Grf                                          $972.58
27281         Arthrodesis, Sacroiliac Joint (Including                       $1,125.30
27282         Arthrd Symphysis Pubis W/Obtg Grf                                $778.94
27284         Arthrd Hip Jt W/Obtg Grf                                       $1,531.59
27286         Arthrd Hip Jt W/Obtg Grf W/Subtrchntric Osteot                 $1,567.78
27290         Interpelviabdl Amp Hindquarter Amp                             $1,529.64
27295         Disrtcj Hip                                                    $1,231.79
27299         Unlis Px Pelvis/Hip Jt                                             $0.00
27301         I&D Dp Absc Bursa/Hmtma Thi/Kne Region                          $549.04
27303         Inc Dp W/Opng B1 Cortex Femur/Kne                               $628.91
27304         Incision, Deep, With Opening Of Bone Cortex (Eg, For            $338.80
27305         Fasct Iliotibl Tx Opn                                           $454.24
27306         Tx Prq Adduxor/Hamstring 1 Tdn Spx                              $377.93
27307         Tx Prq Adduxor/Hamstring Mlt Tdn                                $456.01
27310         Arthrt Kne W/Expl Drg/Rmvl Fb                                   $684.56
27311         Arthrotomy, Knee, For Infection, With Exploration, Drainage    $1,052.70
27315         Neurectomy, Hamstring Muscle                                    $474.90
27320         Neurectomy, Popliteal (Gastrocnemius)                           $460.07
27323         Bx Soft Tiss Thi/Kne Area Supfc                                  $173.65
27324         Bx Soft Tiss Thi/Kne Area Dp                                    $370.32
27327         Exc Tum Thi/Kne Area Subq                                       $385.94
27328         Exc Tum Thi/Kne Area Dp Subfscal/Im                             $407.03
27329         Rad Rescj Tum Soft Tiss Thi/Kne Area                            $957.09
27330         Arthrt Kne W/Synval Bx Only                                      $386.09
27331         Arthrt Kne W/Jt Expl Bx/Rmvl Loose/Fb                           $460.26
27332         Arthrt W/Exc Semilunar Crtlg Kne Medial/Lat                     $623.51
27333         Arthrt W/Exc Semilunar Crtlg Kne Medial&Lat                     $563.66
27334         Arthrt W/Synvct Kne Ant/Pst                                      $653.37
27335         Arthrt W/Synvct Kne Ant&Pst W/Pop Area                           $740.89
27340         Exc Prepatellar Bursa                                           $349.60
27345         Exc Synval Cst Pop Space                                        $465.40
27347         Exc Les Meniscus/Capsl Kne                                      $450.80
27350         Patellectomy/Hemipatellectomy                                   $623.79
27355         Exc/Curtg B1 Cst/B9 Tum Femur                                    $586.43
27356         Exc/Curtg B1 Cst/B9 Tum Femur W/Algrft                           $704.82
27357         Exc/Curtg B1 Cst/B9 Tum Femur W/Agrft                            $782.95
27358         Exc/Curtg B1 Cst/B9 Tum Femur W/Int Fixj                         $302.32
27360         Prtl Exc B1 Femur Prox Tibia&/Fibula                            $824.22
27361         Partial Excision (Craterization, Saucerization, Or Diaphysec    $968.00
27365         Rad Rescj Tum B1 Femur/Kne                                     $1,143.98
27370         Njx Kne Arthg                                                   $477.25
27372         Rmvl Fb Dp Thi Region/Kne Area                                  $438.55
27373         Arthroscopy Knee, Diagnostic (Sep Proc)                         $484.00
27374         Arthroscopy Knee Surgical Debride W/Cart Shaving               $1,302.82
27376         Arthrscpy Knee Srgcl; W/Synovl Biopsy                           $435.60
27377         Arthrscpy Knee Srgcl; W/Rmvl Loose Bdy                          $484.00
27378         Arthrscpy Knee Srgcl; W/Meniscectmy                            $1,960.20
27379         Arthrscpy Knee Srgcl;W/Plica Resctn &/Shlf Resctn               $363.00
27380         Sutr Infrapatellar Tdn Prim                                     $580.95
27381         Sutr Infrapatellar Tdn 2 Rcnstj W/Fscal/Tdn Grf                 $786.61
27385         Sutr Quadriceps/Hamstring Musc Rpt Prim                         $619.84
27386         Sutr Quadriceps/Hamstring Musc Rpt 2 Rcnstj                     $812.23
27390         Tx Opn Hamstring Kne Hip 1 Tdn                                  $424.49

                                              Page 33
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                            Amount
27391         Tx Opn Hamstring Kne Hip Mlt Tdn 1 Leg                $558.99
27392         Tx Opn Hamstring Kne Hip Mlt Tdn Bi                   $685.27
27393         Lngth Hamstring Tdn 1 Tdn                             $496.19
27394         Lngth Hamstring Tdn Mlt Tdn 1 Leg                     $640.21
27395         Lngth Hamstring Tdn Mlt Tdn Bi                        $859.92
27396         Trnspl Hamstring Tdn Patella 1 Tdn                    $605.80
27397         Trnspl Hamstring Tdn Patella Mlt Tdn                  $827.89
27400         Tr Tdn/Musc Hamstrings Femur                          $662.23
27403         Arthrt W/Meniscus Rpr Kne                             $628.35
27405         Rpr 1 Torn Ligm&/Capsl Kne Coltrl                     $654.42
27407         Rpr 1 Torn Ligm&/Capsl Kne Cruciate                   $753.72
27409         Rpr 1 Torn Ligm&/Capsl Kne Coltrl&Cruciate Ligms      $928.65
27410         Sec Rpr Rptd/Svrd Lig W/Wo Mnsctmy; Clltrl/Crct      $1,512.50
27411         Sut Sec Rep Trn Rupt Lig Knee Collateral             $1,512.50
27412         Autol Chondrocyte Impltj Kne                         $1,608.25
27413         Sut Sec Rep Trn Rupt Lig Knee Collateral Or Crucia   $1,512.50
27414         Sutr Sec Lig W/Wo Mnsctmy Knee Clltrl&Cruct Lig      $1,875.50
27415         Ostchndrl Algrft Kne Opn                             $1,633.50
27416         Advncmt Pes Anserinus Slocum Type Proc (Sep Proc)    $1,875.50
27418         Ant Tib Tubercleplasty                                $801.60
27420         Rcnstj Dislocating Patella                            $728.17
27422         Rcnstj Dislc Patella W/Xtnsr Relignmt&/Musc Rls       $726.62
27424         Rcnstj Dislc Patella W/Patellectomy                   $727.05
27425         Lat Retinacular Rls Opn                               $430.81
27427         Ligmous Rcnstj Agmntj Kne Xtr-Articular               $695.23
27428         Ligmous Rcnstj Agmntj Kne Intra-Articular Opn        $1,022.94
27429         Ligmous Rcnstj Agmntj Kne Intra-Articular Xtr        $1,136.37
27430         Quadricepsplasty                                      $717.68
27435         Capsul Pst Capsular Rls Kne                           $724.35
27437         Arthrp Patella W/O Prosth                             $632.92
27438         Arthrp Patella W/Prosth                               $802.89
27440         Arthrp Kne Tibl Platu                                 $676.28
27441         Arthrp Kne Tibl Platu W/Dbrdmt&Prtl Synvct            $719.33
27442         Arthrp Fem Condyles/Tibl Platu Kne                    $847.15
27443         Arthrp Fem Condyles/Tibl Platu Kne Dbrdmt&Prtl        $795.50
27444         Arthroplasty, Knee, Total;                           $1,308.80
27445         Arthrp Kne Hinge Prosth                              $1,227.69
27446         Arthrp Kne Condyle&Platu Medial/Lat Cmprt            $1,106.90
27447         Arthrp Kne Condyle&Platu Medial&Lat Cmprts           $1,476.23
27448         Osteot Femur Shft/Supracondylar W/O Fixj              $802.14
27449         Osteotomy, Femur, Shaft Or Supracondylar, Without    $1,052.70
27450         Osteot Femur Shft/Supracondylar W/Fixj               $1,003.98
27452         Osteotomy, Femur, Shaft Or Supracondylar, With       $1,633.50
27454         Osteot Mlt W/Relignmt Imed Rod Fem Shft              $1,231.85
27455         Osteot Prox Tibia Fib Exc/Osteot Before Epiphysl      $925.83
27457         Osteot Prox Tibia Fib Exc/Osteot After Epiphysl       $955.70
27460         Osteotomy, Proximal Tibia, Including Fibular         $1,452.00
27462         Osteotomy, Proximal Tibia, Including Fibular         $1,694.00
27465         Ostpl Femur Shrt                                      $985.86
27466         Ostpl Femur Lngth                                    $1,136.84
27468         Ostpl Femur Cmbn Lngth&Shrt W/Fem Sgm Tr             $1,293.25
27470         Rpr Non/Mal Femur Dstl H/N W/O Grf                   $1,141.13
27472         Rpr Non/Mal Femur Dstl H/N W/Iliac/Autog B1 Grf      $1,247.08
27475         Arrst Epiphysl Dstl Femur                             $641.22
27477         Arrst Epiphysl Tibfib Prox                            $713.97

                                           Page 34
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
27479         Arrst Epiphysl Cmbn Dstl Femur Prox Tibfib                      $925.94
27485         Arrst Hemiepiphysl Dstl Femur/Prox Tibia/Fibula                 $660.22
27486         Revj Tot Kne Arthrp +-Algrft 1 Comp                            $1,338.17
27487         Revj Tot Kne Arthrp Fem&Entire Tibl Comp                       $1,715.03
27488         Rmvl Prosth Tot Kne Prosth Mma +-Insj Spacer                   $1,117.00
27495         Proph Tx N/P/Pltwr +-Mma Femur                                 $1,105.72
27496         Dcmprn Fasct Thi&/Kne 1 Cmprt                                   $474.48
27497         Dcmprn Fasct Thi&/Kne 1 Dbrdmt Nv Musc&/Nrv                     $515.12
27498         Dcmprn Fasct Thi&/Kne Mlt Cmprts                                $568.68
27499         Dcmprn Fasct Thi&/Kne Mlt Dbrdmt Nv Musc&/Nrv                   $648.70
27500         Cltx Fem Shft Fx W/O Mnpj                                       $515.71
27501         Cltx Sprcndylr/Trnscndylr Fem Fx W/O Mnpj                       $537.79
27502         Cltx Fem Shft Fx W/Mnpj +-Skn/Skel Tracj                        $763.32
27503         Cltx Sprcndylr/Trnscndylr Fem Fx W/Mnpj                         $769.16
27504         Treatment Of Open Femoral Shaft Fracture (Including Supracon    $830.07
27506         Optx Fem Shft Fx W/Insj Imed Implt +-Screw                     $1,228.53
27507         Optx Fem Shft Fx W/Plate/Screws +-Cerclage                      $978.02
27508         Cltx Fem Fx Dstl End Medial/Lat Condyle W/O Mnpj                $510.89
27509         Prq Skel Fixj Fem Fx Dstl End                                   $628.88
27510         Cltx Fem Fx Dstl End Medial/Lat Condyle W/Mnpj                  $664.20
27511         Optx Fem Sprcndylr/Trnscndylr Fx W/O Ntrcndylr                 $1,010.75
27512         Treatment Of Open Femoral Fracture, Distal End, Medial Or La    $939.78
27513         Optx Fem Sprcndylr/Trnscndylr Fx W/Ntrcndylr Xtn               $1,296.30
27514         Optx Fem Fx Dstl End Med/Lat Cndyl +-Int/Xtrnl                 $1,248.54
27516         Cltx Dstl Fem Epiphysl Sep W/O Mnpj                             $501.82
27517         Cltx Dstl Fem Epiphysl Sep W/Mnpj +-Skn/Skel                    $711.90
27518         Treatment Of Open Distal Femoral Epiphyseal Separation, With    $886.65
27519         Optx Dstl Fem Epiphysl Sep +-Int/Xtrnl Fixj                    $1,086.57
27520         Cltx Patellar Fx W/O Mnpj                                       $316.12
27522         Treatment Of Open Patellar Fracture, With Uncomplicated Soft    $550.96
27524         Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr                  $739.02
27530         Cltx Tibl Fx Prox W/O Mnpj                                      $380.71
27532         Cltx Tibl Fx Prox +-Mnpj W/Skel Tracj                           $607.80
27534         Treatment Of Open Tibial Fracture, Proximal (Plateau), With     $847.66
27535         Optx Tibl Fx Prox Unicondylar +-Int/Xtrnl Fixj                  $876.03
27536         Optx Tibl Fx Prox Bicondylar +-Int Fixj                        $1,110.23
27537         Open Treatment Of Closed Or Open Tibial Fracture, Proximal (   $1,242.34
27538         Cltx Intercondylar Spi&/Tubrst Fx Kne +-Mnpj                    $472.59
27540         Optx Ntrcndylr Spi&/Tubrst Fx Kne +-Fixj                        $922.13
27550         Cltx Kne Dislc W/O Anes                                         $487.97
27552         Cltx Kne Dislc Req Anes                                         $599.22
27554         Treatment Of Open Knee Dislocation, With Uncomplicated Soft     $758.65
27556         Optx Kne Dislc +-Int/Xtrnl Fixj W/O Rpr/Agmntj                 $1,061.55
27557         Optx Kne Dislc +-Fixj W/Prim Ligmous Rpr                       $1,220.51
27558         Optx Kne Dislc +-Fixj W/Rpr W/Agmntj                           $1,261.44
27560         Cltx Patellar Dislc W/O Anes                                    $365.55
27562         Cltx Patellar Dislc Req Anes                                    $424.50
27564         Treatment Of Open Patellar Dislocation, With Uncomplicated S    $621.69
27566         Optx Patellar Dislc +-Prtl/Tot Patellectomy                     $879.09
27570         Mnpj Kne Jt Under General Anes                                  $142.86
27580         Arthrd Kne Any Tq                                              $1,393.39
27590         Amp Thi Thru Femur                                              $774.02
27591         Amp Thi Thru Femur Lvl Immt Fitg Tq W/1St Cst                   $876.76
27592         Amp Thi Thru Femur Opn Circular Guillotine                      $671.40
27594         Amp Thi Thru Femur Sec Clsr/Scar Revj                           $497.30

                                            Page 35
                           MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
27596         Amp Thi Thru Femur Re-Amp                                       $719.72
27598         Disrtcj Kne                                                     $720.76
27599         Unlis Px Femur/Kne                                                 $0.00
27600         Dcmprn Fasct Leg Ant&/Lat Cmprts Only                           $417.41
27601         Dcmprn Fasct Leg Pst Cmprt Only                                 $428.03
27602         Dcmprn Fasct Leg Ant&/Lat&Pst Cmprt                             $510.61
27603         I&D Leg/Ankle Dp Absc/Hmtma                                     $600.28
27604         I&D Leg/Ankle Infct Bursa                                       $506.29
27605         Tx Prq Achll Tdn Spx Local Anes                                 $447.22
27606         Tx Prq Achll Tdn Spx General Anes                               $548.54
27607         Inc Leg/Ankle                                                   $590.39
27608         Incision, Deep, With Opening Of Bone Cortex (Eg, For            $810.70
27610         Arthrt Ankle W/Expl Drg/Rmvl Fb                                 $625.39
27611         Arthrotomy, Ankle, For Infection, With Exploration, Drainage    $810.70
27612         Arthrt Pst Capsular Rls Ankle +-Achll Tdn Lngth                 $546.44
27613         Bx Soft Tiss Leg/Ankle Area Supfc                               $226.42
27614         Bx Soft Tiss Leg/Ankle Area Dp                                  $562.09
27615         Rad Rescj Tum Soft Tiss Leg/Ankle Area                          $922.19
27618         Exc Tum Leg/Ankle Area Subq Tiss                                $548.42
27619         Exc Tum Leg/Ankle Area Dp                                       $750.71
27620         Arthrt Ankle W/Jt Expl +-Bx +-Rmvl Loose/Fb                     $464.44
27625         Arthrt W/Synvct Ankle                                           $605.32
27626         Arthrt W/Synvct Ankle W/Tenosynvct                              $648.15
27630         Exc Les Tdn Shth/Capsl Leg&/Ankle                               $536.43
27635         Exc/Curtg B1 Cst/B9 Tum Tib/Fibula                              $591.97
27637         Exc/Curtg B1 Cst/B9 Tum Tib/Fibula W/Agrft                      $739.87
27638         Exc/Curtg B1 Cst/B9 Tum Tib/Fibula W/Algrft                     $772.31
27640         Prtl Exc B1 Tib                                                 $894.22
27641         Prtl Exc B1 Fibula                                              $726.89
27645         Rad Rescj Tum B1 Tib                                           $1,076.20
27646         Rad Rescj Tum B1 Fibula                                         $962.14
27647         Rad Rescj Tum B1 Talus/Calcaneus                                $823.50
27648         Njx Ankle Arthg                                                 $383.36
27650         Rpr Prim Opn/Prq Rptd Achll Tdn                                 $702.00
27652         Rpr Prim Opn/Prq Rptd Achll Tdn W/Grf                           $748.66
27654         Rpr Sec Achll Tdn +-Grf                                         $706.57
27656         Rpr Fscal Dfct Leg                                              $556.47
27658         Rpr Flxr Tdn Leg Prim W/O Grf Ea Tdn                            $554.16
27659         Rpr Flxr Tdn Leg Sec +-Grf Ea Tdn                               $713.73
27664         Rpr Xtnsr Tdn Leg Prim W/O Grf Ea Tdn                           $613.11
27665         Rpr Xtnsr Tdn Leg Sec +-Grf Ea Tdn                              $641.38
27675         Rpr Dislocating Proneal Tdn W/O Fibular Osteot                  $528.79
27676         Rpr Dislocating Proneal Tdn Fibular Osteot                      $617.79
27680         Tnols Flxr/Xtnsr Tdn Leg&/Ankle 1 Ea Tdn                        $442.53
27681         Tnols Flxr/Xtnsr Tdn Leg&/Ankle Mlt Tdn                         $517.08
27685         Lngth/Shrt Tdn Leg/Ankle 1 Tdn Spx                              $583.23
27686         Lngth/Shrt Tdn Leg/Ankle Mlt Tdn Same Inc Ea                    $788.86
27687         Gastrcn Recession                                               $473.67
27690         Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Supfc                 $620.19
27691         Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Dp                    $725.48
27692         Tr/Trnspl 1 Tdn W/Musc Redirion/Rerouting Ea Tdn                $116.40
27695         Rpr Prim Disrupted Ligm Ankle Coltrl                            $503.23
27696         Rpr Prim Disrupted Ligm Ankle Bth Coltrl Ligms                  $602.74
27698         Rpr Sec Disrupted Ligm Ankle Coltrl                             $668.29
27700         Arthrp Ankle                                                    $612.76

                                              Page 36
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
27702         Arthrp Ankle W/Implt Tot Ankle                                  $980.92
27703         Arthrp Ankle Revj Tot Ankle                                    $1,106.64
27704         Rmvl Ankle Implt                                                $515.82
27705         Osteot Tib                                                      $758.16
27707         Osteot Fibula                                                   $375.04
27709         Osteot Tibfib                                                   $737.48
27712         Osteot Mlt W/Relignmt Imed Rod                                 $1,020.84
27715         Ostpl Tibfib Lngth/Shrt                                        $1,030.45
27720         Rpr Non/Mal Tib W/O Grf                                         $865.93
27722         Rpr Non/Mal Tibia W/Sliding Grf                                 $857.88
27724         Rpr Non/Mal Tibia W/Iliac/Oth Agrft                            $1,236.01
27725         Rpr Non/Mal Tibia Synostosis W/Fibula Any Meth                 $1,123.00
27727         Rpr Cgen Pseudarthrosis Tibia                                   $992.83
27730         Arrst Epiphysl Opn Dstl Tibia                                   $960.72
27732         Arrst Epiphysl Opn Dstl Fibula                                  $652.78
27734         Arrst Epiphysl Opn Dstl Tibfib                                  $592.60
27740         Arrst Epiphysl Any Meth Tibfib                                 $1,163.76
27742         Arrst Epiphysl Any Meth Tibfib&Dstl Femur                       $916.38
27745         Proph Tx N/P/Pltwr +-Mma Tibia                                  $742.60
27750         Cltx Tibl Shft Fx W/O Mnpj                                      $336.36
27752         Cltx Tibl Shft Fx W/Mnpj +-Skel Tracj                           $527.46
27754         Treatment Of Open Tibial Shaft Fracture, With Uncomplicated     $489.55
27756         Prq Skel Fixj Tibl Shft Fx                                      $536.85
27758         Optx Tibl Shft Fx W/Plate/Screws +-Cerclage                     $845.04
27759         Tx Tibl Shft Fx Imed Implt +-Screws&/Cerclage                   $984.69
27760         Cltx Medial Malls Fx W/O Mnpj                                   $323.22
27762         Cltx Medial Malls Fx W/Mnpj +-Skn/Skel Tracj                    $490.64
27764         Treatment Of Open Distal Tibial Fracture (Medial Malleolus),    $383.64
27766         Optx Medial Malls Fx +-Int/Xtrnl Fixj                           $630.61
27780         Cltx Prox Fibula/Shft Fx W/O Mnpj                               $294.88
27781         Cltx Prox Fibula/Shft Fx W/Mnpj                                 $423.87
27782         Treatment Of Open Proximal Fibula Or Shaft Fracture, With Un    $356.38
27784         Optx Prox Fibula/Shft Fx +-Int/Xtrnl Fixj                       $548.65
27786         Cltx Dstl Fibular Fx Lat Malls W/O Mnpj                         $310.22
27788         Cltx Dstl Fibular Fx Lat Malls W/Mnpj                           $431.79
27790         Treatment Of Open Distal Fibular Fracture (Lateral Malleolus    $340.17
27792         Optx Dstl Fibular Fx Lat Malls +-Int/Xtrnl Fixj                 $590.09
27800         Treatment Of Closed Tibia And Fibula Fractures, Shafts; With    $265.30
27802         Treatment Of Closed Tibia And Fibula Fractures, Shafts; With    $519.57
27804         Treatment Of Open Tibia And Fibula Fractures, Shafts, With U    $629.28
27806         Open Treatment Of Closed Or Open Tibia And Fibula Fractures,    $863.88
27808         Cltx Bimal Ankle Fx W/Potts W/O Mnpj                            $331.80
27810         Cltx Bimal Ankle Fx W/Potts W/Mnpj                              $479.95
27812         Treatment Of Open Bimalleolar Ankle Fracture, With Uncomplic    $461.95
27814         Optx Bimal Ankle Fx +-Int/Xtrnl Fixj                            $783.89
27816         Cltx Trimal Ankle Fx W/O Mnpj                                   $308.43
27818         Cltx Trimal Ankle Fx W/Mnpj                                     $499.01
27820         Treatment Of Open Trimalleolar Ankle Fracture, With Uncompli    $539.92
27822         Optx Trimal Ankle Fx Med&/Lat W/O Fixj Pst Lip                  $861.62
27823         Optx Trimal Ankle Fx Med&/Lat W/Fixj Pst Lip                    $985.20
27824         Cltx Fx W8 Brg Artclr Prtn Dstl Tibia W/O Mnpj                  $330.06
27825         Cltx Fx W8 Brg Artclr Prtn Dstl Tib W/Skel Tracj                $571.73
27826         Optx Fx W8 Brg Artclr Surf Dstl Tib Fixj Fib                    $700.99
27827         Optx Fx W8 Brg Artclr Surf Dstl Tib Fixj Tib                   $1,084.38
27828         Optx Fx W8 Brg Artclr Surf Dstl Tib Fixj Tibfib                $1,222.50

                                            Page 37
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
27829         Optx Dstl Tibfib Jt Disruption +-Int/Xtrnl Fixj                $489.67
27830         Cltx Prox Tibfib Jt Dislc W/O Anes                             $349.67
27831         Cltx Prox Tibfib Jt Dislc Req Anes                             $361.77
27832         Optx Prox Tibfib Jt Dislc W/Exc Prox Fib                       $511.65
27840         Cltx Ankle Dislc W/O Anes                                      $335.88
27842         Cltx Ankle Dislc Req Anes +-Prq Skel Fixj                      $454.43
27844         Treatment Of Open Ankle Dislocation, With Uncomplicated Soft   $572.70
27846         Optx Ankle Dislc W/O Rpr/Int Fixj                              $720.75
27848         Optx Ankle Dislc W/Rpr/Int/Xtrnl Fixj                          $848.11
27850         Arthroscopy,Ankle,Diagnostic(Seperate Procedure)               $484.00
27851         Arthroscopy,Ankle,Surgical;Debride/Drill/Resection             $605.00
27852         Arthroscopy,Ankle,Surgical;With Synovial Biopsy                $810.70
27853         Arthroscopy,Ankle,Surgical;Remove Loose Body                   $883.30
27860         Mnpj Ankle Under General Anes                                  $175.82
27870         Arthrd Ankle Opn                                               $997.67
27871         Arthrd Tibfib Jt Prox/Dstl                                     $683.75
27880         Amp Leg Thru Tibfib                                            $781.67
27881         Amp Leg Thru Tibfib W/Immt Fitg Tq W/1St Cst                   $867.15
27882         Amp Leg Thru Tibfib Opn Circular Guillotine                    $636.94
27884         Amp Leg Thru Tibfib Sec Clsr/Scar Revj                         $575.72
27886         Amp Leg Thru Tibfib Re-Amp                                     $652.00
27888         Amp Ankle-Malli Tibfib W/Plstc Clsr&Rescj Nrv                  $700.06
27889         Ankle Disrtcj                                                  $676.98
27892         Dcmprn Fasct Leg Ant&/Lat W/Dbrdmt Musc&/Nrv                   $531.49
27893         Dcmprn Fasct Leg Pst W/Dbrdmt Musc&/Nrv                        $528.02
27894         Dcmprn Fasct Leg Ant&/Lat&Pst W/Dbrdmt Musc&/Nrv               $741.95
27899         Unlis Px Leg/Ankle                                               $0.00
28001         I&D Bursa Foot                                                 $329.51
28002         I&D Belw Fsca Foot 1 Bursal Space                              $463.45
28003         I&D Belw Fsca Foot Mlt Areas                                   $644.54
28004         Deep Infection, Below Fascia, Requiring Deep                   $895.40
28005         Inc B1 Cortex Foot                                             $611.71
28006         Incision, Deep, With Opening Of Bone Cortex (Eg, For           $568.70
28008         Fasct Foot&/Toe                                                $400.86
28010         Tx Prq Toe 1 Tdn                                               $327.10
28011         Tx Prq Toe Mlt Tdn                                             $453.64
28020         Arthrt W/Expl Drg/Rmvl Loose/Fb Ntrtrsl/Tars Jt                $476.19
28022         Arthrt W/Expl Drg/Rmvl Loose/Fb Mttarphlngl Jt                 $426.90
28024         Arthrt W/Expl Drg/Rmvl Loose/Fb Iphal Jt                       $413.98
28030         Neurectomy, Intrinsic Musculature Of Foot                      $401.90
28035         Rls Tarsal Tunnel Pst Tibl Nrv Dcmprn                          $426.97
28043         Exc Tum Foot Subq Tiss                                         $365.21
28045         Exc Tum Foot Dp Subfscal Im                                    $429.86
28046         Rad Rescj Tum Soft Tiss Foot                                   $778.68
28050         Arthrt W/Bx Intertarsal/Tars Jt                                $396.23
28052         Arthrt W/Bx Metatarsophalangeal Jt                             $389.97
28054         Arthrt W/Bx Iphal Jt                                           $362.94
28060         Fasct Plntar Fsca Prtl Spx                                     $462.02
28062         Fasct Plntar Fsca Rad Spx                                      $545.34
28070         Synvct Intertarsal/Tars Jt Ea                                  $441.05
28072         Synvct Metatarsophalangeal Jt Ea                               $436.77
28080         Exc Interdgtal Morton Neuroma 1 Ea                             $374.25
28086         Synvct Tdn Shth Foot Flxr                                      $557.56
28088         Synvct Tdn Shth Foot Xtnsr                                     $426.46
28090         Exc Les Tdn Tdn Shth/Capsl W/Synvct Foot                       $412.19

                                            Page 38
                           MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                              Amount
28092         Exc Les Tdn Tdn Shth/Capsl W/Synvct Toe Ea              $389.06
28100         Exc/Curtg Cst/B9 Tum Talus/Calcaneus                    $584.71
28102         Exc/Curtg Cst/B9 Tum Talus/Clcns W/Iliac/Agrft          $556.78
28103         Exc/Curtg Cst/B9 Tum Talus/Calcaneus W/Algrft           $592.97
28104         Exc/Curtg Cst/B9 Tum Tarsal/Metar                       $456.45
28106         Exc/Curtg Cst/B9 Tum Tarsal/Metar W/Iliac/Agrft         $484.22
28107         Exc/Curtg Cst/B9 Tum Tarsal/Metar W/Algrft              $507.82
28108         Exc/Curtg Cst/B9 Tum Phalanges Foot                     $379.24
28109         Excision Or Curettage Of Bone Cyst Or Benign            $363.00
28110         Ostectomy Prtl 5Th Metar Head Spx                       $396.17
28111         Ostectomy Compl 1St Metar Head                          $479.80
28112         Ostectomy Compl Oth Metar Head 2Nd 3Rd/4Th              $440.87
28113         Ostectomy Compl 5Th Metar Head                          $458.08
28114         Ostc Compl All Metar Heads W/Prtl Prox Phalangc         $867.54
28116         Ostectomy Tarsal Coalition                              $602.37
28118         Ostectomy Calcaneus                                     $521.18
28119         Ostectomy Calcaneus Spur +-Plntar Fscal Rls             $463.86
28120         Prtl Exc B1 Talus/Calcaneus                             $551.62
28121         Partial Excision (Craterization, Saucerization,         $568.70
28122         Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus         $607.14
28123         Partial Excision (Craterization, Saucerization,         $459.80
28124         Prtl Exc B1 Phalanx Toe                                 $432.98
28126         Rescj Prtl/Compl Phlngl Base Ea Toe                     $350.06
28130         Talectomy Astragalectomy                                $601.62
28140         Metatarsectomy                                          $600.35
28150         Phalangectomy Toe Ea Toe                                $396.34
28153         Rescj Condyle Dstl End Phalanx Ea Toe                   $357.48
28160         Hemiphalangc/Iphal Jt Exc Toe                           $371.91
28171         Rad Rescj Tum B1 Tarsal Xcp Talus/Calcaneus             $621.19
28173         Rad Rescj Tum B1 Metar                                  $680.69
28175         Rad Rescj Tum B1 Phalanx Toe                            $506.07
28190         Rmvl Fb Foot Subq                                       $318.63
28192         Rmvl Fb Foot Dp                                         $433.31
28193         Rmvl Fb Foot Comp                                       $476.38
28200         Rpr Tdn Flxr Foot 1/2 W/O Fr Grf Ea Tdn                  $417.18
28202         Rpr Tdn Flxr Foot Sec W/Fr Grf Ea Tdn                    $595.31
28208         Rpr Tdn Xtnsr Foot 1/2 Ea Tdn                           $400.56
28210         Rpr Tdn Xtnsr Foot Sec W/Fr Grf Ea Tdn                   $534.56
28220         Tnols Flxr Foot 1 Tdn                                   $402.72
28222         Tnols Flxr Foot Mlt Tdn                                 $464.58
28225         Tnols Xtnsr Foot 1 Tdn                                  $352.77
28226         Tnols Xtnsr Foot Mlt Tdn                                $404.14
28230         Tx Opn Tdn Flxr Foot 1/Mlt Tdn Spx                      $392.05
28232         Tx Opn Tdn Flxr Toe 1 Tdn Spx                           $356.49
28234         Tx Opn Xtnsr Foot/Toe Ea Tdn                            $360.00
28236         Transfer Of Tendon, Anterior Tibial Into Tarsal Bone    $703.03
28238         Rcnstj Pst Tibl Tdn W/Exc Accessory Tarsl Navclr        $632.18
28240         Tx Lngth/Rls Abduxor Hallucis Musc                      $396.66
28250         Div Plntar Fsca&Musc Spx                                $499.00
28260         Capsul Midfoot Medial Rls Only Spx                      $608.64
28261         Capsul Midfoot W/Tdn Lngth                              $843.97
28262         Capsul Midfoot W/Pst Talotibl Capsul&Tdn Lngth         $1,222.28
28264         Capsul Midtarsl                                         $768.07
28270         Capsul Mttarphlngl Jt +-Tenorrhaphy Ea Jt Spx           $425.76
28272         Capsul Iphal Jt Ea Jt Spx                               $354.84

                                              Page 39
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
28280         Syndactylization Toes                                           $493.56
28285         Corrj Hammertoe                                                 $419.98
28286         Corrj Cock-Up 5Th Toe W/Plstc Skn Clsr                          $410.82
28288         Ostc Prtl Exostc/Condylc Metar Head                             $452.64
28289         Hallux Rgdus Corrj W/Cheilc                                     $637.24
28290         Corrj Hallux Valgus +-Sesmdc Smpl Exostectomy                   $505.96
28292         Corrj Hallux Valgus +-Sesmdc Kelr Mcbride/Mayo                  $595.33
28293         Corrj Hallux Valgus +-Sesmdc Rescj Jt W/Implt                   $799.77
28294         Corrj Hallux Valgus +-Sesmdc W/Tdn Trnspls                      $655.19
28296         Corrj Hallux Valgus +-Sesmdc W/Metar Osteot                     $702.30
28297         Corrj Hallux Valgus +-Sesmdc Lapidus-Typ Px                     $739.35
28298         Corrj Hallux Valgus +-Sesmdc Phalanx Osteot                     $617.96
28299         Corrj Hallux Valgus +-Sesmdc 2 Osteot                           $773.38
28300         Osteot Calcaneus +-Int Fixj                                     $898.49
28302         Osteot Talus                                                    $891.49
28304         Osteot Tarsal B1S Oth/Thn Calcaneus/Talus                       $688.85
28305         Osteot Tarsal Oth/Thn Calcaneus/Talus W/Agrft                   $816.18
28306         Osteot +-Lngth Shrt/Corrj 1St Metar                             $520.86
28307         Osteot +-Lngth Shrt/Corrj 1St Metar Xcp 1St Toe                 $694.19
28308         Osteot +-Lngth Shrt/Corrj Metar Xcp 1St Ea                      $455.01
28309         Osteot +-Lngth Shrt/Angular Corrj Metar Mlt                     $850.96
28310         Osteot Shrt Corrj Prox Phalanx 1St Toe                          $467.67
28312         Osteot Shrt Corrj Oth Phalanges Any Toe                         $418.40
28313         Rcnstj Angular Dfrm Toe Soft Tiss Px Only                       $454.86
28315         Sesmdc 1St Toe Spx                                              $426.17
28320         Rpr Non/Mal Tarsal B1S                                          $651.50
28322         Rpr Non/Mal Metar +-B1 Grf                                      $738.31
28340         Rcnstj Toe Macrodactyly Soft Tiss Rescj                         $566.07
28341         Rcnstj Toe Macrodactyly Req B1 Rescj                            $635.44
28344         Rcnstj Toe Polydactyly                                          $435.56
28345         Rcnstj Toe Syndactyly +-Skn Grf Ea Web                          $517.02
28360         Rcnstj Cl Foot                                                  $973.14
28400         Cltx Calcaneal Fx W/O Mnpj                                      $251.18
28405         Cltx Calcaneal Fx W/Mnpj                                        $402.39
28406         Prq Skel Fixj Calcaneal Fx W/Mnpj                               $526.27
28410         Treatment Of Open Calcaneal Fracture, With Uncomplicated Sof    $405.03
28415         Optx Calcaneal Fx +-Int/Xtrnl Fixj                             $1,188.89
28420         Optx Calcaneal Fx W/Prim Iliac/Oth Autog B1 Grf                $1,206.49
28430         Cltx Talus Fx W/O Mnpj                                          $240.09
28435         Cltx Talus Fx W/Mnpj                                            $313.73
28436         Prq Skel Fixj Talus Fx W/Mnpj                                   $423.49
28440         Treatment Of Open Talus Fracture, With Uncomplicated Soft Ti    $280.83
28445         Optx Talus Fx +-Int/Xtrnl Fixj                                 $1,048.36
28450         Tx Tarsal B1 Fx Xcp Talus&Calcn W/O Mnpj                        $231.77
28455         Tx Tarsal B1 Fx Xcp Talus&Calcn W/Mnpj                          $281.50
28456         Prq Skel Fixj Tarsl Fx Xcp Talus&Calcns W/Mnpj                  $271.30
28460         Treatment Of Open Tarsal Bone Fracture (Except Talus And Cal    $460.92
28465         Optx Tarsl Fx Xcp Talus&Calcn                                   $536.70
28470         Cltx Metar Fx W/O Mnpj                                          $228.23
28475         Cltx Metar Fx W/Mnpj                                            $278.72
28476         Prq Skel Fixj Metar Fx W/Mnpj                                   $330.43
28480         Treatment Of Open Metatarsal Fracture, With Uncomplicated So    $254.61
28485         Optx Metar Fx +-Int/Xtrnl Fixj                                  $454.56
28490         Cltx Fx Grt Toe Phlx/Phlg W/O Mnpj                              $127.91
28495         Cltx Fx Grt Toe Phlx/Phlg W/Mnpj                                $159.64

                                            Page 40
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
28496         Prq Skel Fixj Fx Grt Toe Phlx/Phlg W/Mnpj                       $457.80
28500         Treatment Of Open Fracture Great Toe, Phalanx Or Phalanges,     $152.49
28505         Optx Fx Grt Toe Phlx/Phlg +-Int/Xtrnl Fixj                      $520.87
28510         Cltx Fx Phlx/Phlg Oth/Thn Grt Toe W/O Mnpj                      $119.51
28515         Cltx Fx Phlx/Phlg Oth/Thn Grt Toe W/Mnpj                        $148.14
28520         Treatment Of Open Fracture, Phalanx Or Phalanges, Other Than    $129.37
28525         Optx Fx Phlx/Phlg Oth/Thn Grt Toe                               $485.13
28530         Cltx Sesamoid Fx                                                $122.04
28531         Optx Sesamoid Fx +-Int Fixj                                     $431.94
28540         Cltx Tarsal B1 Dislc Oth/Thn Talotarsal W/O Anes                $192.77
28545         Cltx Tarsal B1 Dislc Oth/Thn Talotarsal Req Anes                $212.19
28546         Prq Skel Fixj Tarsl Dislc Xcp Talotarsal W/Mnpj                 $429.97
28550         Treatment Of Open Tarsal Bone Dislocation, With Uncomplicate    $195.61
28555         Optx Tarsal B1 Dislc +-Int/Xtrnl Fixj                           $697.56
28570         Cltx Talotarsal Jt Dislc W/O Anes                               $178.50
28575         Cltx Talotarsal Jt Dislc Req Anes                               $305.14
28576         Prq Skel Fixj Talotarsal Jt Dislc W/Mnpj                        $553.64
28580         Treatment Of Open Talotarsal Joint Dislocation, With Uncompl    $110.05
28585         Optx Talotarsal Jt Dislc +-Int/Xtrnl Fixj                       $650.54
28600         Cltx Tars Jt Dislc W/O Anes                                     $202.51
28605         Cltx Tars Jt Dislc Req Anes                                     $254.85
28606         Prq Skel Fixj Tars Jt Dislc W/Mnpj                              $800.94
28610         Treatment Of Open Tarsometatarsal Joint Dislocation, With Un    $227.70
28615         Optx Tars Jt Dislc +-Int/Xtrnl Fixj                             $634.45
28630         Cltx Metatarsophlngl Jt Dislc W/O Anes                          $116.57
28635         Cltx Metatarsophlngl Jt Dislc Req Anes                          $143.73
28636         Prq Skel Fixj Metatarsophlngl Jt Dislc W/Mnpj                   $346.76
28640         Treatment Of Open Metatarsophalangeal Joint Dislocation, Wit    $145.59
28645         Optx Metatarsophlngl Jt Dislc +-Int/Xtrnl Fixj                  $392.36
28660         Cltx Iphal Jt Dislc W/O Anes                                    $110.01
28665         Cltx Iphal Jt Dislc Req Anes                                    $143.74
28666         Prq Skel Fixj Iphal Jt Dislc W/Mnpj                             $334.58
28670         Treatment Of Open Interphalangeal Joint Dislocation, With Un    $120.75
28675         Optx Iphal Jt Dislc +-Int/Xtrnl Fixj                            $450.67
28705         Arthrd Pantalar                                                $1,259.31
28715         Arthrd Triple                                                   $934.39
28725         Arthrd Subtalar                                                 $816.00
28730         Arthrd Midtarsl/Tars Mlt/Transvrs                               $784.36
28735         Arthrd Midtarsl/Tars Mlt/Transvrs W/Osteot                      $765.45
28737         Arthrd W/Tdn Lngth&Advmnt Tarsl Nvclr-Cuneiform                 $677.17
28740         Arthrd Midtarsl/Tars 1 Jt                                       $777.64
28750         Arthrd Grt Toe Metatarsophlngl Jt                               $796.27
28755         Arthrd Grt Toe Iphal Jt                                         $458.57
28760         Arthrd W/Xtnsr Hallucis Longus Tr 1St Metar Nck                 $635.08
28800         Amp Foot Midtarsl                                               $574.75
28805         Amp Foot Transmetar                                             $575.95
28810         Amp Metar W/Toe 1                                               $439.49
28820         Amp Toe Metatarsophlngl Jt                                      $499.90
28825         Amp Toe Iphal Jt                                                $443.67
28890         Eswt Hi Nrg Pfrmd Phys W/Us Gdn Invg Plntar Fsca                $357.09
28899         Unlis Foot/Toes                                                    $0.00
29000         Appl Halo Typ Bdy Cst                                           $211.49
29010         Appl Risser Jacket Localizer Bdy Only                           $210.85
29015         Appl Risser Jacket Localizer Bdy W/Head                         $210.07
29020         Appl Turnbuckle Jacket Bdy Only                                 $207.02

                                            Page 41
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                        Amount
29025         Appl Turnbuckle Jacket Bdy W/Head                  $219.81
29035         Appl Bdy Cst Sho Hips                              $203.87
29040         Appl Bdy Cst Sho Hips W/Head Minerva Typ           $193.83
29044         Appl Bdy Cst Sho Hips W/1 Thi                      $232.16
29046         Appl Bdy Cst Sho Hips W/Bth This                   $226.08
29049         Appl Cst Figure-Of-8                                $84.21
29050         Interstitial Pressure Test                           $0.00
29055         Appl Cst Sho Spica                                 $180.87
29058         Appl Cst Plaster Velpeau                           $110.60
29065         Appl Cst Sho Hand Long Arm                          $84.19
29075         Appl Cst Elbw Fngr Short Arm                        $77.86
29085         Appl Cst Hand&Lwr F/Arm Gauntlet                    $82.69
29086         Appl Cst Fngr                                       $59.96
29105         Appl Long Arm Splnt Sho Hand                        $80.86
29125         Appl Short Arm Splnt F/Arm-Hand Static              $61.03
29126         Appl Short Arm Splnt F/Arm-Hand Dynamic             $75.05
29130         Appl Fngr Splnt Static                              $37.54
29131         Appl Fngr Splnt Dynamic                             $48.82
29200         Strpg Thorax                                        $53.69
29220         Strpg Lw Bk                                         $53.44
29240         Strpg Sho                                           $60.36
29260         Strpg Elbw/Wrst                                     $49.96
29280         Strpg Hand/Fngr                                     $50.65
29305         Appl Hip Spica Cst 1 Leg                           $206.53
29325         Appl Hip Spica Cst 1&One-Half Spica/Bth Legs       $224.74
29345         Appl Long Leg Cst Thi-Toe                          $123.34
29355         Appl Long Leg Cst Thi-Toe Walker/Ambl Typ          $127.15
29358         Appl Long Leg Cst Brace                            $134.32
29365         Appl Cylinder Cst Thi Ankle                        $110.30
29405         Appl Short Leg Cst Belw Kne-Toe                     $80.53
29425         Appl Short Leg Cst Belw Kne-Toe Walking/Ambl Typ    $87.72
29435         Appl Patellar Tdn Bearing Ptb Cst                  $107.01
29440         Adding Walker Previously Applied Cst                $49.00
29445         Appl Rgd Tot Contact Leg Cst                       $142.17
29450         Appl Clubfoot Cst W/Molding/Mnpj Long/Short Leg    $137.12
29455         Application Of Clubfoot Cast With Molding Or        $60.50
29505         Appl Long Leg Splnt Thi Ankle/Toes                  $70.61
29515         Appl Short Leg Splnt Calf Foot                      $61.55
29520         Strpg Hip                                           $52.75
29530         Strpg Kne                                           $52.53
29540         Strpg Ankle&/Foot                                   $36.05
29550         Strpg Toes                                          $34.96
29580         Strpg Unna Boot                                     $47.46
29590         Denis-Browne Splnt Strpg                            $49.48
29700         Rmvl/Bivalv Gauntlet Boot/Bdy Cst                   $56.67
29705         Rmvl/Bivalv Full Arm/Full Leg Cst                   $62.11
29710         Rmvl/Bivalv Sho/Hip Spica Minerva/Risser Jacket    $112.99
29715         Rmvl/Bivalv Turnbuckle Jacket                       $80.80
29720         Rpr Spica Bdy Cst/Jacket                            $70.44
29730         Windowing Cst                                       $61.37
29740         Wedging Cst Xcp Clubfoot Csts                       $90.04
29750         Wedging Clubfoot Cst                                $92.75
29751         Wedging Of Clubfoot Cast                            $36.30
29799         Unlis Px Csting/Strpg                                $0.00
29800         Arthrs Tmprmand Jt Dx +-Synval Bx Spx              $540.80

                                           Page 42
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                          Amount
29804         Arthrs Tmprmand Jt Surg                             $643.21
29805         Arthrs Sho Dx +-Synval Bx Spx                       $466.96
29806         Arthrs Sho Surg Capsulorrhaphy                     $1,033.36
29807         Shoulder Scope, Repair Cartilage Tear              $1,007.12
29815         Arthroscopy Shouldr Dx (Sep Pro)                    $514.16
29819         Arthrs Sho Surg W/Rmvl Loose Bdy/Fb                 $579.83
29820         Arthrs Sho Surg Synvct Prtl                         $535.51
29821         Arthrs Sho Surg Synvct Compl                        $584.71
29822         Arthrs Sho Surg Dbrdmt Lmtd                         $567.46
29823         Arthrs Sho Surg Dbrdmt X10Sv                        $620.14
29824         Shoulder Scope, Partial Removal Collar Bone         $631.89
29825         Arthrs Sho Surg W/Lss&Rescj Ads +-Mnpj              $578.70
29826         Shoulder Scope, Bone Shaving                        $667.73
29827         Shoulder Scope, Rotator Cuff Repair                $1,077.28
29830         Arthrs Elbw Dx +-Synval Bx Spx                      $445.06
29834         Arthrs Elbw Surg W/Rmvl Loose Bdy/Fb                $485.30
29835         Arthrs Elbw Surg Synvct Prtl                        $495.41
29836         Arthrs Elbw Surg Synvct Compl                       $576.81
29837         Arthrs Elbw Surg Dbrdmt Lmtd                        $523.17
29838         Arthrs Elbw Surg Dbrdmt X10Sv                       $586.85
29840         Arthrs Wrst Dx +-Synval Bx Spx                       $431.60
29843         Arthrs Wrst Surg Infctj Lvg&Drg                      $466.61
29844         Arthrs Wrst Surg Synvct Prtl                         $488.30
29845         Arthrs Wrst Surg Synvct Compl                       $554.48
29846         Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Jt Dbrdmt     $512.47
29847         Arthrs Wrst Surg Int Fixj F/Fx/Ins                   $531.49
29848         Ndsc Wrst Surg W/Rls Transvrs Carpl Ligm            $438.62
29850         Arthrs Aid Tx Spi&/Fx Kne W/O Fixj                   $525.68
29851         Arthrs Aid Tx Spi&/Fx Kne W/Fixj                     $929.84
29855         Arthrs Aid Tx Tibl Fx Prox Unicondylar              $783.48
29856         Arthrs Aid Tx Tibl Fx Prox Bicondylar              $1,009.07
29860         Arthrs Hip Dx +-Synval Bx Spx                       $604.99
29861         Arthrs Hip Surg W/Rmvl Loose Bdy/Fb                 $668.40
29862         Arthrs Hip Chndpls Abrasj Arthrp&/Rescj Labrum      $744.01
29863         Arthrs Hip W/Synvct                                 $742.59
29866         Arthrs Kne Ostchndrl Agrft Hrvg                    $1,046.12
29867         Arthrs Kne Ostchndrl Algrft                        $1,249.56
29868         Arthrs Kne Menscl Trnsplj Med/Lat                  $1,696.18
29870         Arthrs Kne Dx +-Synval Bx Spx                       $397.17
29871         Arthrs Kne Infctj Lvg&Drg                           $497.66
29872         Arthroscopy, Knee, Surgical                            $0.00
29873         Arthrs Kne Lat Rls                                  $492.07
29874         Arthrs Kne Rmvl Loose Bdy/Fb                        $523.59
29875         Arthrs Kne Synvct Lmtd Spx                          $487.97
29876         Arthrs Kne Synvct Major 2/> Cmprts                  $601.10
29877         Arthrs Kne Dbrdmt/Shvg Artclr Crtlg Chndpls         $565.16
29879         Arthrs Kne Abrasj Arthrp/Mlt Drlg/Microfx           $609.68
29880         Arthrs Kne Surg W/Meniscectomy Med&Lat W/Shvg       $638.88
29881         Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg       $591.72
29882         Arthrs Kne Surg W/Meniscus Rpr Med/Lat              $635.17
29883         Arthrs Kne Surg W/Meniscus Rpr Med&Lat              $801.94
29884         Arthrs Kne Surg W/Lss Ads +-Mnpj Spx                $562.95
29885         Arthrs Kne Drlg Osteo Diss Grfg                     $686.48
29886         Arthrs Kne Drlg Osteo Diss Les                      $577.90
29887         Arthrs Kne Drlg Osteo Diss Les Int Fixj             $683.52

                                            Page 43
                           MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
29888         Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj                $982.33
29889         Arthrs Aided Pst Cruciate Ligm Rpr/Agmntj/Rcnstj               $1,146.61
29890         Arthroscopy, Ankle, Diagnostic, With Or Without Synovial Bio       $0.00
29891         Arthrs Ankle Exc Ostchndrl Dfct W/Drlg Dfct                     $639.04
29892         Arthrs Aid Rpr Les/Talar Dome Fx/Tibl Plafond Fx                $674.68
29893         Ndsc Plntar Fasct                                               $454.96
29894         Arthrs Ankle Tibtlr&Fibltlr W/Rmvl Loose Bdy/Fb                 $515.30
29895         Arthrs Ankle Tibtlr&Fibltlr Surg Synvct Prtl                    $505.05
29896         Arthroscopy, Ankle, Surgical                                       $0.00
29897         Arthrs Ankle Tibtlr&Fibltlr Surg Dbrdmt Lmtd                    $528.42
29898         Arthrs Ankle Tibtlr&Fibltlr Surg Dbrdmt X10Sv                   $589.14
29899         Arthrs Ankle Tibtlr&Fibltlr Surg W/Ankle Arthrd                 $973.57
29900         Arthrs Mtcarphlngl Jt Dx W/Synval Bx                            $446.40
29901         Arthrs Mtcarphlngl Jt Surg W/Dbrdmt                             $492.81
29902         Arthrs Mtcarphlngl Jt W/Rdctj Ur Coltrl Ligm                    $527.98
29909         Unlisted Proc Arthroscopy                                          $0.00
29999         Unlis Px Arthrs                                                    $0.00
30000         Drg Absc/Hmtma Nsl Int Appr                                     $211.28
30020         Drg Absc/Hmtma Nsl Septum                                       $179.79
30100         Bx Intransl                                                     $112.80
30110         Exc Nsl Polyp Smpl                                              $189.25
30111         Excision, Nasal Polyp(S), Simple                                $121.00
30115         Exc Nsl Polyp X10Sv                                             $323.90
30116         Excision, Nasal Polyp(S), Extensive                             $326.70
30117         Exc/Dstrj Intransl Les Int Appr                                 $288.91
30118         Exc/Dstrj Intransl Les Xtrnl Appr Lat Rhixomy                   $659.46
30120         Exc/Surg Plning Skn Nose Rhinophyma                             $418.27
30124         Exc Dermoid Cst Nose Smpl Skn Subq                              $236.16
30125         Exc Dermoid Cst Nose Cplx Under B1/Crtlg                        $509.59
30130         Exc Inf Turbinate Prtl/Compl Any Meth                           $264.99
30140         Sbmcsl Rescj Inf Turbinate Prtl/Compl Any Meth                  $284.46
30150         Rhinectomy Prtl                                                 $658.04
30160         Rhinectomy Tot                                                  $674.92
30200         Njx Turbinate Ther                                                $94.05
30210         Displmt Ther Proetz Typ                                         $123.63
30220         Insj Nsl Septal Prosth Button                                   $227.11
30300         Rmvl Fb Intransl Off Typ Px                                     $218.82
30310         Rmvl Fb Intransl Req General Anes                               $196.95
30320         Rmvl Fb Intransl Lat Rhixomy                                    $349.85
30400         Rhinp Prim Lat&Alar Crtlgs&/Elvtn Nsl Tip                       $740.21
30410         Rhinp Prim Complete Xtrnl Parts                                 $936.28
30420         Rhinp Prim W/Major Septal Rpr                                  $1,106.75
30430         Rhinp Sec Minor Revj Sm Amount Nsl Tip Work                     $595.13
30435         Rhinp Sec Intrm Revj B1Y Work Osteot                            $878.40
30450         Rhinp Sec Major Revj Nsl Tip Work&Osteot                       $1,285.39
30460         Rhinp Dfrm W/Colum Lngth Tip Only                               $696.42
30462         Rhinp Dfrm Colum Lngth Tip Septum Osteot                       $1,323.17
30465         Rpr Nsl Vstblr Stenosis                                         $761.55
30520         Septop/Sbmcsl Rescj                                             $420.45
30540         Rpr Choanal Atresia Intransl                                    $520.26
30545         Rpr Choanal Atresia Transpalatine                               $778.72
30560         Lss Intransl Synechia                                           $231.18
30580         Rpr Fstl Oromax                                                 $535.65
30600         Rpr Fstl Oronsl                                                 $489.36
30620         Septal/Oth Intransl Dermtp                                      $455.57

                                              Page 44
                         MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
30630         Rpr Nsl Septal Prforations                                      $516.37
30800         Cauterization Turbinates, Unilateral Or Bilateral (Separate       $35.00
30801         Caut&/Abltj Mucosa Inf Turbs Uni/Bi Supfc                       $124.01
30802         Caut&/Abltj Mucosa Inf Turbs Uni/Bi Intramural                  $182.08
30805         Cauterization Turbinates, Unilateral Or Bilateral (Separate       $84.70
30820         Cryosurgery Of Turbinates, Unilateral Or Bilateral                $84.70
30901         Ctrl Nsl Hemrrg Ant Smpl Lmtd Caut&/Packing                       $99.32
30902         Control Nasal Hemorrhage, Anterior, Simple (Cauterization)        $36.30
30903         Ctrl Nsl Hemrrg Ant Cplx X10Sv Caut&/Packing                    $165.44
30904         Control Nasal Hemorrhage, Anterior, Complex (Cauterization W      $36.30
31225         Maxillectomy W/O Orb Exntj                                     $1,286.17
31230         Maxillectomy W/Orb Exntj En Bloc                               $1,447.10
31231         Nsl Ndsc Dx Uni/Bi Spx                                          $174.77
31233         Nsl/Sinus Ndsc Dx Max Sinusc                                    $253.08
31235         Nsl/Sinus Ndsc Dx Sphenoid Sinusoscopy                          $293.76
31237         Nsl/Sinus Ndsc Surg W/Bx Polypc/Dbrdmt Spx                      $318.63
31238         Nsl/Sinus Ndsc Surg W/Ctrl Nsl Hemrrg                           $332.13
31239         Nsl/Sinus Ndsc Surg W/Dacryocstorhinostomy                      $649.20
31240         Nsl/Sinus Ndsc Surg W/Concha Bullosa Rescj                      $170.67
31245         Nasal/Sinus Endoscopy, Surgical, With Osteomeatal Complex (O    $315.09
31246         Nasal/Sinus Endoscopy, Surgical, With Osteomeatal Complex (O    $388.61
31247         Nasal/Sinus Endoscopy, Surgical, With Osteomeatal Complex (O    $436.85
31248         Nasal/Sinus Endoscopy, Surgical, With Osteomeatal Complex (O    $461.74
31249         Nasal/Sinus Endoscopy, Surgical, With Osteomeatal Complex (O    $548.49
31250         Nasal Endoscopy, Diagnostic, With Or Without Biopsy (Include      $97.04
31251         Nasal/Sinus Endoscopy, Surgical, With Osteomeatal Complex (O    $575.72
31252         Nasal Endoscopy, Surgical; With Nasal Polypectomy               $249.49
31254         Nsl/Sinus Ndsc Surg W/Ethmdct Prtl Ant                          $294.65
31255         Nsl/Sinus Ndsc Surg W/Ethmdct Tot Ant&Pst                       $435.05
31256         Nsl/Sinus Ndsc Surg W/Max Antrostomy                            $212.38
31258         Nasal Endoscopy, Surgical; With Removal Of Foreign Body(S)      $194.93
31260         Maxillary Sinus Endoscopy, Diagnostic, With Or Without Biops    $196.56
31261         Nasal/Sinus Endoscopy, Surgical, With Anterior And Posterior    $499.86
31262         Nasal/Sinus Endoscopy, Surgical, With Anterior And Posterior    $574.16
31263         Maxillary Sinus Endoscopy, Surgical; With Removal Of Foreign    $303.84
31264         Nasal/Sinus Endoscopy, Surgical, With Anterior And Posterior    $621.23
31265         Maxillary Sinus Endoscopy, Surgical; With Removal Of Cyst       $371.60
31266         Nasal/Sinus Endoscopy, Surgical, With Anterior And Posterior    $646.52
31267         Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus                $344.17
31268         Maxillary Sinus Endoscopy, Surgical; With Removal Of Fungus     $229.03
31269         Nasal/Sinus Endoscopy, Surgical, With Anterior And Posterior    $735.21
31270         Sphenoid Endoscopy, Diagnostic, With Or Without Biopsy (Sepa    $137.63
31271         Nasal/Sinus Endoscopy, Surgical, With Anterior And Posterior    $760.50
31275         Sphenoid Endoscopy, Surgical;                                   $387.48
31276         Nsl/Sinus Ndsc W/Frnt Sinus Expl                                $549.37
31277         Sphenoid Endoscopy, Surgical; With Removal Of Mucous Membran    $447.47
31280         Nasal/Sinus Endoscopy, Surgical, With Anterior And Posterior    $632.51
31281         Nasal/Sinus Endoscopy, Surgical, With Anterior And Posterior    $706.81
31282         Nasal/Sinus Endoscopy, Surgical, With Anterior And Posterior    $753.88
31283         Nasal/Sinus Endoscopy, Surgical, With Anterior And Posterior    $779.17
31284         Nasal/Sinus Endoscopy, Surgical, With Anterior And Posterior    $867.47
31285         Sinus Endoscopy, Two Or More Sinuses, Unilateral                $263.61
31286         Nasal/Sinus Endoscopy, Surgical, With Anterior And Posterior    $893.14
31287         Nsl/Sinus Ndsc Surg W/Sphendt                                   $250.34
31288         Nsl/Sinus Ndsc Sphendt Rmvl Tiss Sphenoid Sinus                 $290.57

                                          Page 45
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
31290         Nsl/Sinus Ndsc Rpr Cerebsp Flu Leak Ethmoid                    $1,145.26
31291         Nsl/Sinus Ndsc Rpr Cerebsp Flu Leak Sphenoid                   $1,221.38
31292         Nsl/Sinus Ndsc Surg W/Medial/Inf Orb Wall Dcmprn                $989.87
31293         Nsl/Sinus Ndsc Medial Orb&Inf Orb Wall Dcmprn                  $1,072.77
31294         Nsl/Sinus Ndsc Surg W/Optic Nrv Dcmprn                         $1,236.11
31299         Unlis Px Accessory Sinuses                                         $0.00
31300         Lryngot W/Rmvl Tum/Laryngocele Cordectomy                      $1,020.52
31320         Laryngotomy Thyrotomy Laryngofissure Dx                         $479.93
31360         Largtom Tot W/O Rad Nck Dsj                                    $1,205.01
31365         Largtom Tot W/Rad Nck Dsj                                      $1,628.60
31367         Largtom Stot Supraglottic W/O Rad Nck Dsj                      $1,527.74
31368         Largtom Stot Supraglottic W/Rad Nck Dsj                        $1,870.01
31370         Prtl Largtom Hemilargtom Hrzntl                                $1,493.82
31375         Prtl Largtom Hemilargtom Later>                                $1,383.99
31380         Prtl Largtom Hemilargtom Anter>                                $1,381.31
31382         Prtl Largtom Hemilargtom Antero-Latero-Ver                     $1,440.56
31390         Pharyngolargtom W/Rad Nck Dsj W/O Rcnstj                       $1,897.64
31395         Pharyngolargtom W/Rad Nck Dsj W/Rcnstj                         $2,188.11
31400         Arytenoidectomy/Arytenoidopexy Xtrnl Appr                       $784.77
31420         Epiglottidectomy                                                $773.70
31500         Intubaj Endotracheal Emer Px                                    $114.41
31502         Tracht Tube Chng Prior Estbm Fstl Trc                             $80.71
31505         Largsc Indir Dx Spx                                               $82.14
31510         Largsc Indir W/Bx                                               $203.90
31511         Largsc Indir W/Rmvl Fb                                          $207.06
31512         Largsc Indir W/Rmvl Les                                         $206.98
31513         Largsc Indir W/Vocal Cord Njx                                   $140.14
31515         Largsc +-Tracheoscopy Aspir                                     $208.38
31520         Largsc +-Tracheoscopy Dx Nb                                     $162.56
31525         Largsc +-Tracheoscopy Dx Xcp Nb                                 $248.10
31526         Largsc +-Trachesc Mcrscp/Tlscp                                  $168.81
31527         Largsc +-Tracheoscopy W/Insj Obturator                          $201.65
31528         Largsc +-Tracheoscopy W/Dilat 1St                               $149.17
31529         Largsc +-Tracheoscopy W/Dilat Sbsq                              $171.83
31530         Largsc W/Fb Rmvl                                                $210.30
31531         Largsc Fb Rmvl Mcrscp/Tlscp                                     $230.23
31535         Largsc W/Bx                                                      $202.74
31536         Largsc W/Bx W/Oprating Mcrscp/Tlscp                              $228.38
31540         Largsc Exc Tum&/Stripping Cords/Epigl                           $262.65
31541         Largsc Exc Tum&/Strpg Cords/Epigl Mcrscp/Tlscp                  $287.25
31545         Largsc Mcrscp/Tlscp Rmvl Les Vocal C/D Flap                     $383.28
31546         Largsc Mcrscp/Tlscp Rmvl Les Vocal C/D Grf                      $585.87
31560         Largsc W/Arytenoidectomy                                        $337.97
31561         Largsc W/Arytenoidectomy W/Oprating Mcrscp/Tlscp                $367.83
31570         Largsc W/Njx Vocal Cord Ther                                    $365.53
31571         Largsc W/Njx Vocal Cord Ther W/Mcrscp/Tlscp                     $269.75
31575         Largsc Flx Fibopt Dx                                            $113.79
31576         Largsc Flx Fibopt W/Bx                                           $212.25
31577         Largsc Flx Fibopt W/Rmvl Fb                                     $237.34
31578         Largsc Flx Fibopt W/Rmvl Les                                    $271.00
31579         Largsc Flx/Rgd Fibopt W/Stroboscopy                             $230.88
31580         Laryngoplasty Laryn Web 2 Stg W/Keel Insj&Rmvl                  $910.28
31582         Laryngp Laryn Stenosis Grf/Core Mold W/Tracht                  $1,516.70
31584         Laryngoplasty W/Opn Rdctj Fx                                   $1,334.18
31585         Treatment Of Closed Laryngeal Fracture; Without Manipulation    $391.65

                                             Page 46
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
31586         Treatment Of Closed Laryngeal Fracture; With Closed Manipula    $632.39
31587         Laryngoplasty Cricoid Splt                                      $857.05
31588         Laryngoplasty Nos                                              $1,012.28
31590         Laryn Reinnervation Neuromuscular Pedcl                         $605.99
31595         Sctj Recrt Laryn Nrv Ther Spx Uni                               $620.89
31599         Unlis Px Larx                                                      $0.00
31600         Trachs Plnd Spx                                                 $401.25
31601         Trachs Plnd Spx Under 2 Yr                                      $272.91
31603         Trachs Emer Px Transtracheal                                    $234.48
31605         Trachs Emer Px Cricothyr Memb                                   $193.03
31610         Trachs Fenestration Px W/Skn Flaps                              $632.53
31611         Constj Tracheoesophgl Fstl&Insj Sp Prosth                       $447.01
31612         Tracheal Pnxr Prq W/Transtracheal Aspir&/Njx                      $77.72
31613         Tracheostoma Revj Smpl W/O Flap Rotation                        $387.24
31614         Tracheostoma Revj Cplx W/Flap Rotation                          $575.89
31615         Tracheobrnchsc Thru Est Trachs Inc                              $180.99
31620         Endobrncl Us Bronchoscopic Dx/Ther Ivntj                        $268.05
31622         Brnchsc Dx +-Cell Washg Spx                                     $262.99
31623         Brnchsc Brushing/Protected Brushings                            $298.86
31624         Brnchsc W/Brncl Alveolar Lavage                                 $270.33
31625         Brnchsc Brncl/Endobrncl Bx 1+ Sits                              $329.28
31628         Brnchsc W/Transbrncl Lung Bx 1 Lobe                             $350.73
31629         Brnchsc Ndl Bx Trachea Main Stem&/Bronchusi                     $176.51
31630         Brnchsc W/Tracheal/Brncl Dilat/Clsd Rdctj Fx                    $229.94
31631         Brnchsc W/Placement Tracheal Stent                              $251.61
31632         Brnchsc W/Transbrncl Lung Bx Ea Lobe                              $73.13
31633         Brnchsc W/Transbrncl Ndl Aspir Bx Ea Lobe                         $89.43
31635         Brnchsc W/Removal Foreign Body                                  $208.18
31636         Brnchsc W/Placement Brncl Stent 1St Bronchus                    $241.22
31637         Brnchsc Ea Major Bronchus Stented                                 $86.05
31638         Brnchsc Revj Tracheal/Brncl Stent Ins Prev Sess                 $267.39
31640         Brnchsc W/Excision Tumor                                        $288.20
31641         Brnchsc Dstrj Tum/Relief Stenosis Oth/Thn Exc                   $279.50
31643         Brnchsc Plmt Cath Intrcv Radioelmnt Appl                        $185.47
31645         Brnchsc W/Ther Aspir Tracheobrncl Tree 1St                      $168.32
31646         Brnchsc W/Ther Aspir Tracheobrncl Tree Sbsq                     $146.69
31656         Brnchsc Njx Contrast Sgmtl Bronchog                             $119.87
31659         Bronchoscopy; With Other Bronchoscopic Procedures               $241.58
31700         Catheterization, Transglottic (Separate Procedure)              $128.15
31708         Instillation Of Contrast Material For Laryngography Or Bronc      $76.67
31710         Catheterization For Bronchography, With Or Without Instillat      $77.31
31715         Transtracheal Njx Bronchograpy                                    $65.84
31717         Cathj W/Brncl Brush Bx                                          $191.72
31719         Transtracheal (Percutaneous) Introduction Of Indwelling Tube    $149.38
31720         Cath Aspir Spx Nasotracheal                                       $95.37
31725         Cath Aspir Spx Tracheobrncl W/Fibersc Bedside                   $146.35
31730         Ttrach Intro Ndl Wire Dil/Stent/Tube O2 Ther                    $194.80
31750         Tracheoplasty Crv                                               $957.93
31755         Tracheoplasty Tracheopharyngeal Fstlj Ea Stg                   $1,169.13
31760         Tracheoplasty Intrathrc                                        $1,301.32
31766         Carinal Rcnstj                                                 $1,791.83
31770         Bronchoplasty Grf Rpr                                          $1,328.43
31775         Bronchoplasty Exc Stenosis&Anast                               $1,454.45
31780         Exc Tracheal Stenosis&Anast Crv                                $1,143.39
31781         Exc Tracheal Stenosis&Anast Cervicothrc                        $1,423.40

                                            Page 47
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
31785         Exc Tracheal Tum/Carc Crv                                      $1,083.60
31786         Exc Tracheal Tum/Carc Thrc                                     $1,483.72
31800         Sutr Tracheal Wnd/Inj Crv                                       $488.21
31805         Sutr Tracheal Wnd/Inj Intrathrc                                 $826.92
31820         Surg Clsr Trachs/Fstl W/O Plstc Rpr                             $385.93
31825         Surg Clsr Trachs/Fstl W/Plstc Rpr                               $556.20
31830         Revj Trachs Scar                                                $392.56
31899         Unlis Px Trachea Bronchi                                           $0.00
32000         Thoracnts Pnxr Pleural Cavity Aspir 1St/Sbsq                    $175.05
32001         Total Lung Lavage (Unilateral)                                  $327.18
32002         Thoracnts W/Insj Tube +-Water Seal Spx                          $208.29
32005         Chem Pleurodesis                                                $330.59
32019         Insj Ndwellg Tun Pleural Cath W/Cuff                            $920.14
32020         Tube Thoracostomy +-Water Seal Spx                              $218.68
32035         Thoracostomy W/Rib Rescj Empyema                                $589.21
32036         Thoracostomy Opn Flap Drg Empyema                               $657.05
32095         Thorcom Lmtd Bx Lng/Pleura                                      $558.11
32100         Thorcom Major W/Expl&Bx                                         $927.24
32110         Thorcom Major Ctrl Traumtc Hemrrg&/Rpr Lng Tear                $1,332.55
32120         Thorcom Major Po Complctjs                                      $760.08
32124         Thorcom Major W/Opn Intrapleural Pneumonolss                    $813.73
32140         Thorcom Major W/Cst Rmvl +-Pleural Px                           $884.98
32141         Thorcom Major Exc-Plctj Bullae +-Any Pleural Px                 $884.47
32150         Thorcom Major W/Rmvl Intrapleural Fb/Fibrin Dep                 $886.57
32151         Thorcom Major W/Rmvl Ipul Fb                                    $897.76
32160         Thorcom Major W/Car Massage                                     $590.78
32200         Pneumonostomy W/Opn Drg Absc/Cst                                $958.00
32201         Pneumonostomy W/Prq Drg Absc/Cst                                $205.40
32215         Pleural Scarification Repeat Pneumothorax                       $742.37
32220         Dcrtctj Pulm Spx Tot                                           $1,487.25
32225         Dcrtctj Pulm Spx Prtl                                           $885.82
32310         Pleurectomy Parietal Spx                                        $854.47
32315         Pleurectomy; Partial                                            $901.70
32320         Dcrtctj&Parietal Pleurectomy                                   $1,463.74
32400         Bx Pleura Prq Ndl                                               $131.05
32402         Bx Pleura Opn                                                   $515.45
32405         Bx Lng/Med Prq Ndl                                              $154.68
32420         Pneumocnts Pnxr Lng Aspir                                       $116.99
32440         Rmvl Lng Tot Pnumec                                            $1,530.94
32442         Tot Pnumec Rescj Sgm Trachea Brnctrac Anast                    $1,672.43
32445         Tot Pnumec Xtrpleural                                          $1,603.89
32450         Pneumonectomy, Extrapleural; With Empyemectomy                 $1,712.25
32480         Rmvl Lng Oth/Thn Tot Pnumec 1 Lobe Lobec                       $1,437.73
32482         Rmvl Lng Oth/Thn Tot Pnumec 2 Lobes Bilobec                    $1,520.73
32484         Rmvl Lng Oth/Thn Tot Pnumec 1 Sgm Sgmectomy                    $1,313.67
32485         Lobectomy, Total Or Segmental; With Bronchoplasty              $1,984.72
32486         Rmvl Lng Xcp Tot Pnumec Sleeve Lobectomy                       $1,524.61
32488         Rmvl Lng Oth/Thn Tot Pnumec Completion Pnumec                  $1,620.11
32490         Lobectomy, Total Or Segmental; With Concomitant Decorticatio   $1,819.89
32491         Rmvl Lng Oth/Thn Tot Pnumec Exc-Plctj Emphy Lng                $1,385.96
32500         Rmvl Lng Oth/Thn Tot Pnumec Wedge Rescj 1/Mlt                  $1,359.79
32501         Rescj&Bronchoplasty Pfrmd Tm Lobec/Sgmectomy                    $258.65
32503         Rescj Apical Lng Tum W/O Ch Wall Rcnstj                        $1,882.01
32504         Rescj Apical Lng Tum W/Ch Wall Rcnstj                          $2,152.81
32520         Resection Of Lung; With Resection Of Chest Wall                $1,356.26

                                            Page 48
                         MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
32522         Resection Of Lung; With Reconstruction Of Chest Wall, Withou   $1,486.06
32525         Resection Of Lung; With Major Reconstruction Of Chest Wall,    $1,617.08
32540         Xtrpleural Encl Empyema Empyemectomy                            $989.70
32545         Extrapleural Enucleation Of Empyema (Empyemectomy); With Lob   $1,332.18
32601         Thrsc Dx Spx Lngs&Pleural Space W/O Bx                          $322.79
32602         Thrsc Dx Spx Lngs&Pleural Space Bx                              $350.55
32603         Thrsc Dx Spx Prcrd Sac W/O Bx                                    $441.51
32604         Thrsc Dx Spx Prcrd Sac Bx                                       $503.97
32605         Thrsc Dx Spx Medstnl Space W/O Bx                               $409.15
32606         Thrsc Dx Spx Medstnl Space W/Bx                                 $485.48
32650         Thrsc W/Pleurodesis                                             $710.39
32651         Thrsc W/Prtl Pulm Dcrtctj                                       $820.05
32652         Thrsc Tot Pulm Dcrtctj Intrapleural Pneumonolss                $1,180.43
32653         Thrsc Rmvl Intrapleural Fb/Fibrin Dep                           $811.87
32654         Thrsc Ctrl Traumtc Hemrrg                                       $814.23
32655         Thrsc Exc-Plctj Bullae Any Pleural Px                           $829.14
32656         Thrsc W/Parietal Pleurectomy                                    $851.27
32657         Thrsc W/Wedge Rescj Lng 1/Mlt                                   $871.39
32658         Thrsc W/Rmvl Clot/Fb From Prcrd Sac                             $775.01
32659         Thrsc Crtj Prcrd Window/Prtl Rescj Prcrd Sac                    $773.87
32660         Thrsc W/Tot Pricardiectomy                                     $1,099.86
32661         Thrsc W/Exc Prcrd Cst Tum/Mass                                   $861.29
32662         Thrsc W/Exc Medstnl Cst Tum/Mass                               $1,034.74
32663         Thrsc W/Lobec Tot/Sgmtl                                        $1,195.16
32664         Thrsc W/Thrc Sympth                                             $892.95
32665         Thrsc W/Esophagomyotomy Heller Typ                              $965.72
32700         Thoracoscopy, Exploratory (Separate Procedure);                 $353.60
32705         Thoracoscopy, Exploratory (Separate Procedure); With Biopsy     $389.24
32800         Rpr Lng Hrna Thru Ch Wall                                       $857.98
32810         Clsr Ch Wall Flwg Opn Flap Drg Empyema                          $839.77
32815         Opn Clsr Major Brncl Fstl                                      $1,405.97
32820         Major Rcnstj Ch Wall Posttraumtc                               $1,363.22
32850         Don Pnumec From Cdvr Don                                           $0.00
32851         Lng Trnspl 1 W/O Card Byp                                      $2,701.98
32852         Lng Trnspl 1 W/Card Byp                                        $3,030.22
32853         Lng Trnspl 2 Bi Seql/En Bloc W/O Card Byp                      $3,250.29
32854         Lng Trnspl 2 Bi Seql/En Bloc W/Card Byp                        $3,492.03
32900         Rescj Ribs Xtrpleural All Stgs                                 $1,237.88
32905         Thoracoplasty Schede Typ/Xtrpleural                            $1,270.26
32906         Thoracop Schede Typ/Xtrpleural Clsr Brncplr Fstl               $1,603.31
32940         Pneumonolss Xtrpriosteal W/Filling/Packing Px                  $1,193.62
32960         Pneumothorax Ther Intrapleural Njx Air                          $138.67
32997         Tot Lng Lvg Uni                                                 $320.26
32999         Unlis Px Lngs&Pleura                                               $0.00
33010         Pricardiocnts 1St                                               $125.20
33011         Pricardiocnts Sbsq                                              $126.66
33015         Tube Pricardiostomy                                             $466.71
33020         Pricardiotomy Rmvl Clot/Fb Prim Px                              $793.51
33025         Crtj Prcrd Window/Prtl Rescj Drg                                $757.66
33030         Pricardiectomy Stot/Compl W/O Card Byp                         $1,165.27
33031         Pricardiectomy Stot/Compl W/Card Byp                           $1,317.61
33035         Complete Ventricular Decortication, With                           $0.00
33050         Exc Prcrd Cst/Tum                                               $908.95
33100         Pericardiectomy (Separate Procedure)                           $1,577.39
33120         Exc Icar Tum Rescj W/Card Byp                                  $1,492.19

                                           Page 49
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
33130         Rescj Xtrnl Car Tum                                            $1,292.57
33140         Transmyocrd Laser Revsc Thorcom Spx                            $1,256.62
33141         Transmyocrd Laser Revsc Pfrmd Tm Oth Opn Car Px                  $265.26
33200         Insertion Of Permanent Pacemaker With Epicardial Electrode(S    $777.49
33201         Insertion Of Permanent Pacemaker With Epicardial Electrode(S    $684.52
33206         Insj/Rplcmt Prm Pm W/Transvns Eltrd Atr                          $439.96
33207         Insj/Rplcmt Prm Pm W/Transvns Eltrd Ventr                        $501.72
33208         Insj/Rplcmt Prm Pm W/Transvns Eltrd Atr&Ventr                    $507.10
33210         Insj/Rplcmt Temp Transvns 1Chmbr Eltrd/Pm Cath                  $177.40
33211         Insj/Rplcmt Temp Transvns 2Chmbr Pacg Eltrds Spx                $183.32
33212         Insj/Rplcmt Pm Pls Gen Only 1Chmbr Atr/Ventr                     $352.18
33213         Insj/Rplcmt Pm Pls Gen Only 2Chmbr                               $397.88
33214         Upg Pm Sys Conv 1Chmbr Sys 2Chmbr Sys                           $496.85
33215         Rpsg Prev Implted Pm/Cvdfb R Atr/R Ventr Eltrd                   $310.97
33216         Insj Eltrd 1Chmbr 1 Eltrd Prm Pm/1Chmbr Cvdfb                   $389.96
33217         Insj Eltrd 2Chmbr 2 Eltrds Prm Pm/2Chmbr Cvdfb                  $389.93
33218         Rpr 1 Eltrd 1Chmbr Prm Pm/1Chmbr Cvdfb                          $381.85
33219         Repair Of Pacemaker; With Replacement Of Pulse Generator        $423.12
33220         Rpr 2 Eltrds 2 Chmbr Prm Pm/2Chmbr Cvdfb                        $383.34
33222         Revj/Relocation Skn Pocket Pm                                   $363.16
33223         Revj Skn Pocket 1/2Chmbr Pacg Cvdfb                             $431.83
33224         Insj Eltrd Car Ven Sys Attch Pm/Cvdfb Pls Gen                    $501.82
33225         Insj Eltrd Car Ven Sys Tm Insj Cvdfb/Pm Pls Gen                  $446.47
33226         Rpsg Prev Implted Car Ven Sys L Ventr Eltrd                      $483.27
33232         Removal Of Permanent Pacemaker                                  $353.25
33233         Rmvl Prm Pm Pls Gen                                              $254.70
33234         Rmvl Transvns Pm Eltrd 1 Lead Sys Atr/Ventr                      $500.03
33235         Rmvl Transvns Pm Eltrd Dual Lead Sys                            $634.47
33236         Rmvl Prm Epicar Pm&Eltrds Thorcom 1 Lead Sys                    $816.10
33237         Rmvl Prm Epicar Pm&Eltrds Thorcom Dual Lead Sys                 $874.35
33238         Rmvl Prm Transvns Eltrd Thorcom                                  $945.66
33240         Insj 1/2Chmbr Pacg Cvdfb Pls Gen                                $479.60
33241         Subq Rmvl 1/2Chmbr Pacg Cvdfb Pls Gen                           $240.33
33242         Repair Of Implantable Cardioverter-Defibrillator Pulse Gener    $499.35
33243         Rmvl 1/2Chmbr Pacg Cvdfb Eltrd Thorcom                         $1,388.26
33244         Rmvl 1/2Chmbr Pacg Cvdfb Eltrd Transvns Xtrj                    $891.89
33245         Insertion Of Epicardial Single Or Dual Chamber Pacing Cardio    $889.08
33246         Insertion Of Epicardial Single Or Dual Chamber Pacing Cardio   $1,261.34
33247         Insertion Or Replacement Of Implantable Cardioverter-Defibri    $800.12
33248         Revision Or Removal Of Automatic Implantable Cardioverter-De   $1,003.99
33249         Insj/Rpsg Lead 1/2Chmbr Cvdfb&Insj Pls Gen                      $879.65
33250         Abltj Arrhytgnic Foc/Pthwy Trc&/Foc                            $1,270.78
33251         Abltj Arrhytgnic Foc/Pthwy Trc&/Foc Card Byp                   $1,474.59
33253         Operative Incisions And Reconstruction Of Atria For Treatmen   $1,846.47
33260         Operative Ablation Of Arrhythmogenic Focus Or Pathway; Witho   $1,279.58
33261         Oprative Abltj Ventr Arrhytgnic Foc W/Card Byp                 $1,498.55
33282         Impltj Pt-Activated Car Event Recorder                          $324.53
33284         Rmvl Impltable Pt-Activated Car Event Recorder                  $235.47
33300         Rpr Car Wnd W/O Byp                                            $1,101.53
33305         Rpr Car Wnd W/Card Byp                                         $1,321.57
33310         Cardiot Expl W/Rmvl Fb Atr/Ventr Thrmb W/O Byp                 $1,153.48
33315         Cardiot Expl Rmvl Fb Atr/Ventr Thrmb Card Byp                  $1,376.41
33320         Sutr Rpr Aorta/Grt Vsl W/O Shunt/Card Byp                      $1,010.25
33321         Sutr Rpr Aorta/Grt Vsl W/Shunt Byp                             $1,245.82
33322         Sutr Rpr Aorta/Grt Vsl W/Card Byp                              $1,273.32

                                            Page 50
                         MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
33330         Insj Grf Aorta/Grt Vsl W/O Shunt/Card Byp                      $1,299.05
33332         Insj Grf Aorta/Grt Vsl W/Shunt Byp                             $1,399.87
33335         Insj Grf Aorta/Grt Vsl W/Card Byp                              $1,794.66
33350         Great Vessel Repair With Other Major Procedure                 $3,872.00
33400         Vlvp Aortic Valve Opn W/Card Byp                               $1,788.82
33401         Vlvp Aortic Valve Opn W/Infl Occlusion                         $1,519.85
33403         Vlvp Aortic Valve W/Transventr Dilat W/Card Byp                $1,574.26
33404         Constj Apical-Aortic Conduit                                   $1,758.90
33405         Rplcmt A-Valve Prostc Xcp Homogrf/Stent< Valve                 $2,165.03
33406         Rplcmt A-Valve Algrft Valve Frhand                             $2,298.85
33407         Valvotomy, Aortic Valve (Commissurotomy); With Cardiopulmona   $2,420.00
33408         Valvotomy, Aortic Valve (Commissurotomy); With Inflow Occlus   $1,936.00
33410         Rplcmt A-Valve Stent< Tiss Valve                               $2,020.32
33411         Rplcmt A-Valve Aortic Annulus Enlgment Nonc Cusp               $2,243.51
33412         Rplcmt A-Valve Konno Procedure                                 $2,543.23
33413         Rplcmt A-Valve Ross Px                                         $2,594.30
33414         Rpr Ventr O/F Trc Obstrcj Patch Enlgment O/F Trc               $1,836.93
33415         Rescj/Inc Subvalvular Tissue                                   $1,613.96
33416         Ventriculomyotomy-Myectomy                                     $1,816.41
33417         Aortoplasty Supravalvular Stenosis                             $1,740.19
33420         Valvotomy Mitral Valve Clsd Hrt                                $1,272.03
33422         Valvotomy Mitral Valve Opn Hrt W/Card Byp                      $1,629.65
33425         Vlvp Mitral Valve W/Card Byp                                   $1,632.30
33426         Vlvp Mitral Valve W/Card Byp W/Prostc Ring                     $2,048.77
33427         Vlvp Mitral Valve W/Card Byp Rad Rcnstj +-Ring                 $2,412.35
33430         Rplcmt Mitral Valve W/Card Byp                                 $2,076.94
33450         Valvotomy, Tricuspid Valve (Commissurotomy)                    $1,815.00
33452         Valvotomy, Tricuspid Valve, With Cardiopulmonary Bypass        $1,400.65
33460         Valvectomy Tricspd Valve W/Card Byp                            $1,443.36
33463         Vlvp Tricspd Valve W/O Ring Insj                               $1,584.90
33464         Vlvp Tricspd Valve W/Ring Insj                                 $1,686.08
33465         Rplcmt Tricspd Valve W/Card Byp                                $1,727.02
33468         Tricspd Valve Rpsg&Plctj Ebstein Anomal                        $1,821.36
33470         Valvotomy Pulm Valve Clsd Hrt Transventr                       $1,307.48
33471         Valvotomy Pulm Valve Clsd Hrt Via P-Art                        $1,335.55
33472         Valvotomy Pulm Valve Opn Hrt W/Infl Occlusion                  $1,409.99
33474         Valvotomy Pulm Valve Opn Hrt W/Card Byp                        $1,398.58
33475         Rplcmt Pulm Valve                                              $1,924.95
33476         R Ventr Rescj Infund Sten +-Commissurotomy                     $1,517.60
33478         O/F Trc Agmntj +-Commissurotomy/Infund Rescj                   $1,650.96
33480         Replacement And/Or Repair, Double Valve Procedure, By Method   $3,997.00
33481         Single Valve Replacement; With Commissurotomy Or Valvuloplas   $3,509.00
33482         Single Valve Replacement; With Commissurotomy Or Valvuloplas   $3,872.00
33483         Double Valve Replacement;                                      $3,818.40
33485         Double Valve Replacement; With Commissurotomy Or Valvuloplas   $4,598.00
33490         Replacement And/Or Repair, Triple Valve Procedure, By Method   $4,840.00
33492         Triple Valve Replacement                                       $4,840.00
33496         Rpr Non-Structural Prostc Valve Dysf Card Byp                  $1,653.35
33500         Rpr C Arven/Arteriocar Chamber Fstl W/Card Byp                 $1,511.43
33501         Rpr C Arven/Arteriocar Chamber Fstl W/O Card Byp               $1,067.81
33502         Rpr Anom C Art From P-Art Origin Lig                           $1,314.93
33503         Rpr Anom C Art From P-Art Origin Grf                           $1,240.63
33504         Rpr Anom C Art From P-Art Origin Grf W/Card Byp                $1,503.51
33505         Rpr Anom C Art W/Constj Intrap-Art Tunnel                      $1,550.56
33506         Rpr Anom C Art From P-Art To Aorta                             $2,015.62

                                           Page 51
                         MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
33507         Rpr Anom Aortic Origin C Art Unroofing/Tlcj                    $1,815.29
33508         Ndsc Surg W/Vid-Asstd Harvest Vein Cab                            $16.85
33510         Cab Vein Only 1 C Ven Grf                                      $1,834.36
33511         Cab Vein Only 2 C Ven Grfs                                     $1,908.89
33512         Cab Vein Only 3 C Ven Grfs                                     $2,012.58
33513         Cab Vein Only 4 C Ven Grfs                                     $2,040.86
33514         Cab Vein Only 5 C Ven Grfs                                     $2,097.81
33516         Cab Vein Only 6/> C Ven Grfs                                   $2,221.05
33517         Cab W/Ven Grf&Artl Grf 1 Vein Grf                                $142.50
33518         Cab W/Ven Grf&Artl Grf 2 Ven Grfs                                $268.89
33519         Cab W/Ven Grf&Artl Grf 3 Ven Grfs                                $394.10
33520         Coronary Artery Bypass, Nonautogenous Graft (Eg, Synthetic O   $2,420.00
33521         Cab W/Ven Grf&Artl Grf 4 Ven Grfs                                $520.86
33522         Cab W/Ven Grf&Artl Grf 5 Ven Grfs                                $647.32
33523         Cab W/Ven Grf&Artl Grf 6/> Ven Grfs                              $773.76
33525         Coronary Artery Bypass, Nonautogenous Graft (Eg, Synthetic O   $3,025.00
33528         Coronary Artery Bypass, Nonautogenous Graft (Eg, Synthetic O   $3,630.00
33530         Roprtj Cab/Valve Px >1 Mo After Original Operj                  $323.98
33532         Myocardial Implntatn One Mor Systmic Arteries                  $2,117.50
33533         Cab W/Artl Grf 1 Artl Grf                                      $1,881.73
33534         Cab W/Artl Grf 2 C Artl Grfs                                   $2,028.27
33535         Cab W/Artl Grf 3 C Artl Grfs                                   $2,146.54
33536         Cab W/Artl Grf 4/> C Artl Grfs                                 $2,230.65
33542         Myocrd Rescj                                                   $1,730.35
33545         Rpr Postinfrcj Ventr Septal Dfct                               $2,161.53
33548         Surg Ventr Rstrj Px W/Prostc Patch Pfrmd                       $2,389.64
33560         Myocardial Operation Combined With Coronary Bypass Procedure       $0.00
33570         Coronary Angioplasty (Endarterectomy) With Or Without Gas, A   $1,328.82
33572         C Endartercomy Opn Any Meth                                     $245.95
33575         Coronary Angioplasty (Endarterectomy) With Or Without Gas, A   $1,815.00
33600         Clsr Atrioventricular Valve Suture/Patch                       $1,673.90
33602         Clsr Semilunar Valve Aortic/Pulm Sutr/Patch                    $1,664.47
33606         Anast P-Art Aorta Damus-Kaye-Stansel Px                        $1,824.20
33608         Rpr Car Anomal Xcp Pulm Atresia Ventr Septl Dfct               $1,881.82
33610         Rpr Car Anomal Surg Enlgment Ventr Septl Dfct                  $1,856.94
33611         Rpr 2 Outlet R Vntrc W/Intraventr Tunnel Rpr                   $1,948.39
33612         Rpr 2 Outlet R Vntrc Rpr R Ventr O/F Trc Obstrcj               $2,079.95
33615         Rpr Car Anomal Clsr Septl Dfct Smpl Fontan Px                  $1,975.11
33617         Rpr Cplx Car Anomal Modf Fontan Px                             $2,168.16
33619         Rpr 1 Vntrc W/O/F Obstrcj&Aortic Arch Hypoplasia               $2,673.38
33640         Repair Atrial Septal Defect, Secundum                              $0.00
33641         Rpr Atr Septal Dfct Secundum W/Card Byp +-Patch                $1,280.59
33643         Repair Atrial Septal Defect, Secundum                              $0.00
33645         Dir/Patch Clsr Sinus Venosus +-Anom Pulm Ven Drg               $1,517.92
33647         Rpr Atr&Ventr Septal Dfct Dir/Patch Clsr                       $1,742.55
33649         Repair Of Tricuspid Atresia (Eg, Fontan, Gago Procedures)      $2,178.00
33660         Rpr Incompl/Prtl Av Canal +-Av Valve Rpr                       $1,752.89
33665         Rpr Intrm/Transj Av Canal +-Av Valve Rpr                       $1,761.50
33670         Rpr Compl Av Canal +-Prostc Valve                              $1,900.93
33681         Clsr 1 Ventr Septal Dfct +- Patch                              $1,853.74
33682         Closure Ventricular Septal Defect                                  $0.00
33684         Clsr V-Septl Dfct W/Pulm Vlvt/Infund Rescj                     $1,791.37
33688         Clsr V-Septl Dfct W/Rmvl P-Art Band +-Gusset                   $1,718.62
33690         Banding P-Art                                                  $1,231.43
33692         Compl Rpr Tetralogy Fallot W/O Pulm Atresia                    $1,843.39

                                           Page 52
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
33694         Compl Rpr T-Fallot W/O Pulm Atresia Tanulr Patch               $2,000.11
33696         Complete Repair Tetralogy Of Fallot; With Closure Of Previou   $3,224.11
33697         Compl Rpr T-Fallot W/Pulm Atresia                              $2,111.22
33698         Complete Repair Tetralogy Of Fallot With Pulmonary Atresia I   $3,353.97
33702         Rpr Sinus Valsalva Fistula                                     $1,620.67
33710         Rpr Sinus Valsalva Fstl W/Rpr V-Septl Dfct                     $1,810.78
33720         Rpr Sinus Valsalva Aneurysm                                    $1,599.03
33722         Clsr Aortico-L Ventr Tunnel                                    $1,754.69
33730         Compl Rpr Anom Ven Return                                      $1,936.56
33732         Rpr C Triatm/Supvalvr Ring Rescj L Atr Memb                    $1,679.23
33735         Atr Septect/Septost Clsd Hrt                                   $1,220.55
33736         Atr Septect/Septost Opn Hrt W/Card Byp                         $1,445.72
33737         Atr Septect/Septost Opn Hrt W/Infl Occlusion                   $1,357.41
33738         Atrial Septectomy Or Septostomy; Transvenous Method, Balloon    $968.00
33739         Atrial Septectomy Or Septostomy; Blade Method (Sang-Park Sep    $968.00
33750         Shunt Subcla P-Art                                             $1,260.22
33755         Shunt Ascending Aorta P-Art                                    $1,279.66
33762         Shunt Descending Aorta P-Art                                   $1,264.53
33764         Shunt Ctr W/Prostc Grf                                         $1,283.77
33766         Shunt Suprior V/C P-Art Flo 1 Lng                              $1,426.37
33767         Shunt Suprior V/C P-Art Flo Bth Lngs                           $1,498.77
33768         Anast Cavopulm 2Nd Suprior V/C                                  $451.77
33770         Rpr Tga W/O Surg Enlgmnt V-Septl Dfct                          $2,139.17
33771         Rpr Tga Enlgmnt V-Septl Dfct                                   $1,976.72
33774         Rpr Tga Atr Baffle W/Card Byp                                  $1,879.58
33775         Rpr Tga Atr Baffle W/Rmvl Pulm Band                            $1,934.69
33776         Rpr Tga Atr Baffle W/Clsr V-Septl Dfct                         $2,073.62
33777         Rpr Tga Atr Baffle Rpr Sbpulmc Obstrcj                         $2,014.75
33778         Rpr Tga Aortic P-Art Rcnstj                                    $2,348.57
33779         Rpr Tga Aortic P-Art Rcnstj W/Rmvl Pulm Band                   $2,033.37
33780         Rpr Tga Aortic P-Art Rcnstj W/Clsr V-Septl Dfct                $2,510.73
33781         Rpr Tga Aortic P-Art Rcnstj Rpr Sbpulmc Obstrcj                $2,095.17
33782         Repair Transposition Of Great Vessels, Atrial Baffle               $0.00
33783         Repair Transposition Of Great Vessels, Atrial Baffle               $0.00
33784         Repair Transposition Of Great Vessels, Atrial Baffle               $0.00
33786         Tot Rpr Truncus Arteriosus                                     $2,297.37
33788         Rimpltj An Anom P-Art                                          $1,594.51
33800         Aortic Ssp Tracheal Dcmprn Spx                                  $959.94
33802         Div Aberrant Vsl Vasc Ring                                     $1,074.37
33803         Div Aberrant Vsl Vasc Ring W/Reanast                           $1,219.02
33810         Creation Of Aortopulmonary Window                              $1,815.00
33812         Creation Of Aortopulmonary Window                              $2,662.00
33813         Obltrj Aortopulm Septal Dfct W/O Card Byp                      $1,307.55
33814         Obltrj Aortopulm Septal Dfct W/Card Byp                        $1,549.26
33820         Rpr Patent Duxus Arteriosus Lig                                $1,016.81
33822         Rpr Patent Duxus Arteriosus Div Under 18 Yr                    $1,089.66
33824         Rpr Patent Duxus Arteriosus Div 18 Yr&Older                    $1,223.25
33830         Patent Ductus Arteriosus; Ligation Or Division When Performe    $302.50
33840         Exc Coarcj Aorta +-Pda W/Dir Anast                             $1,263.44
33845         Exc Coarctation Aorta +-Pda W/Grf                              $1,384.24
33850         Excision Of Coarctation Of Aorta, With Or Without Associated   $2,117.50
33851         Exc Coarcj Aorta W/L Subcla Art/Prostc As Gusset               $1,327.10
33852         Rpr Hypoplstc A-Arch W/Agrft/Prostc                            $1,458.57
33853         Rpr Hypoplstc A-Arch Agrft/Prostc Card Byp                     $1,934.85
33855         Excision Of Coarctation Of Aorta, With Or Without Associated       $0.00

                                            Page 53
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                     Amount
33860         Ascending Aorta Grf W/Card Byp +-Valve Ssp                    $2,232.14
33861         Ascending Aorta Grf +-Valve Ssp W/C Rcnstj                    $2,424.25
33863         As-Aort Grf +-Valve Ssp Aortic Root Rplcmt                    $2,589.94
33865         Ascending Aorta Graft, With Cardiopulmonary Bypass, With Or   $3,622.14
33870         Transvrs Arch Grf W/Card Byp                                  $2,565.30
33875         Dta Grf +-Byp                                                 $1,950.54
33877         Rpr Thoracoaaa W/Grf +-Card Byp                               $2,436.95
33880         Evasc Rpr Dta Coverage Art Origin 1St Endoprosth              $1,869.52
33881         Evasc Rpr Dta Exp Coverage W/O Art Origin                     $1,605.87
33883         Plmt Prox Xtn Prosth Evasc Rpr Dta 1St Xtn                    $1,189.27
33884         Plmt Prox Xtn Prosth Evasc Rpr Dta Ea Prox Xtn                 $442.59
33886         Plmt Dstl Xtn Prosth Dlyd After Evasc Rpr Dta                 $1,026.93
33889         Opn Subcla Crtd Art Trpos Nck Inc Ulat                         $886.35
33891         Byp Grf W/Dta Rpr Nck Inc                                     $1,130.55
33910         P-Art Embolectomy W/Card Byp                                  $1,487.47
33915         P-Art Embolectomy W/O Card Byp                                $1,196.20
33916         Pulm Endartercomy +-Embolectomy W/Card Byp                    $1,529.67
33917         Rpr P-Art Stenosis Rcnstj W/Patch/Grf                         $1,516.79
33918         Repair Of Pulmonary Atresia With Ventricular Septal Defect,   $1,598.89
33919         Repair Of Pulmonary Atresia With Ventricular Septal Defect,   $2,305.60
33920         Rpr Pulm Atresia W/Constj/Rplcmt Conduit                      $1,876.40
33922         Trnsxj P-Art W/Card Byp                                       $1,390.36
33924         Lig&Tkdn Sysic-To-P-Art Shunt W/Cgen Hrt Px                    $308.76
33925         Rpr P-Art Arborizj Anomal Unifclizj W/O Card Byp              $1,856.97
33926         Rpr P-Art Arborizj Anomal Unifclizj W/Card Byp                $2,509.42
33930         Don Cardiectomy-Pnumec                                            $0.00
33935         Hrt-Lng Trnspl W/Rcp Cardiectomy-Pnumec                       $3,734.31
33940         Don Cardiectomy                                                   $0.00
33945         Hrt Trnspl +-Rcp Cardiectomy                                  $2,626.76
33950         Cardiac Transplntatn Removal Donor Heart                          $0.00
33960         Prolng Xtrcorp Crcj 1St 24 Hr                                 $1,006.76
33961         Prolng Xtrcorp Crcj Ea 24 Hr                                   $611.94
33967         Insj Intra-Aortic Balo Assist Dev Prq                          $262.10
33968         Rmvl Intra-Aortic Balo Assist Dev Prq                            $35.55
33970         Insj I-Aort Balo Assist Dev Thru Fem Art Opn                   $369.46
33971         Rmvl I-Aort Balo Assist Dev W/Rpr Fem Art +-Grf                $630.69
33972         Intra-Aortic Balloon Counterpulsation; Monitoring Only         $101.63
33973         Insj I-Aort Balo Assist Dev Thru As-Aort                       $534.92
33974         Rmvl I-Aort Balo Dev From As-Aort Rpr As-Aort                  $900.44
33975         Insj Ventr Assist Dev Xtrcorp 1 Vntrc                         $1,097.63
33976         Insj Ventr Assist Dev Xtrcorp Biventr                         $1,272.80
33977         Rmvl Ventr Assist Dev Xtrcorp 1 Vntrc                         $1,245.19
33978         Rmvl Ventr Assist Dev Xtrcorp Biventr                         $1,371.75
33979         Insj Ventr Assist Dev Impltable Icorp 1 Vntrc                 $2,456.90
33980         Rmvl Ventr Assist Dev Impltable Icorp 1 Vntrc                 $3,255.00
33999         Unlis Car Surg                                                    $0.00
34001         Emblc/Thrmbc Cath Crtd Subcla/Innominate Art                   $799.39
34051         Emblc/Thrmbc Innominate Subcla Art                             $945.91
34101         Emblc/Thrmbc Ax Brach Innominate Subcla Art                    $623.99
34111         Emblc/Thrmbc +-Cath Rdl/Ur Art Arm Inc                         $611.38
34151         Emblc/Thrmbc Rnl Celiac Mesentery A-Iliac Art                 $1,403.88
34201         Emblc/Thrmbc Fempop A-Iliac Art                                $622.82
34203         Emblc/Thrmbc Pop-Tibio-Proneal Art Leg Inc                     $977.89
34401         Thrmbc Dir/W/Cath V/C Iliac Vein Abdl Inc                     $1,382.40
34421         Thrmbc Dir/W/Cath V/C Iliac Fempop Vein Leg Inc                $725.25

                                            Page 54
                         MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                          Amount
34451         Thrmbc Dir/W/Cath V/C Iliac Fempop Vein Abdl&Leg   $1,504.32
34471         Thrmbc Dir/W/Cath Subcla Vein Nck Inc               $619.07
34490         Thrmbc Dir/W/Cath Ax&Subcla Vein Arm Inc            $602.96
34501         Vlvp Fem Vein                                       $976.01
34502         Rcnstj V/C Any Meth                                $1,602.28
34510         Ven Valve Trpos Any Vein Don                       $1,131.14
34520         Cross-> Vein Grf Ven Sys                           $1,056.69
34530         Saphenopop Vein Anast                              $1,037.34
34800         Evasc Rpr Aaa W/Aorto-Aortic Tube Prosth           $1,183.20
34802         Evasc Rpr Aaa W/Mdlr Bfrc Prosth 1 Limb            $1,297.58
34803         Evasc Rpr Aaa W/Mdlr Bfrc Prosth 2 Limbs           $1,371.29
34804         Evasc Rpr Aaa W/Unibdy Bfrc Prosth                 $1,297.95
34805         Evasc Rpr Aaa Aorto-Uniiliac/Aorto-Unifem Prosth   $1,242.25
34808         Evasc Plmt Iliac Art Occlusion Dev                  $218.47
34812         Opn Fem Art Expos Dlvr Evasc Prosth Uni             $357.46
34813         Plmt Fem-Fem Prostc Grf Evasc Aortic Arysm Rpr       $253.23
34820         Iliac Art Expos Prosth/Iliac Occls Evasc Uni        $516.53
34825         Plmt Xtn Prosth Evasc Rpr Arysm/Dsj 1St Vsl         $714.93
34826         Plmt Xtn Prosth Evasc Rpr Arysm/Dsj Ea Vsl          $218.47
34830         Opn Rpr Arysm Rpr Artl Trauma Tube Prosth          $1,832.19
34831         Opn Rpr Arysm Rpr Artl Trma Aortobiiliac Prosth    $1,872.65
34832         Opn Rpr Arysm Rpr Artl Trma Aorto-Bifem Prosth     $1,977.82
34833         Iliac Art Expos W/Crtj Conduit Uni                  $646.18
34834         Brach Art Expos Dplmnt Aortic/Iliac Prosth Uni      $304.82
34900         Evasc Grf Plmt Rpr Iliac Art                        $969.65
35001         Dir Rpr Arysm/&Grf Insj Crtd Subcla Art            $1,202.03
35002         Dir Rpr Arysm&Grf Insj Rptd Arysm Crtd Subcla      $1,228.17
35005         Dir Rpr Arysm&Grf Insj Vrt Art                     $1,066.40
35011         Dir Rpr Arysm&Grf Insj Ax-Brach Art                $1,027.71
35013         Dir Rpr Arysm&Grf Insj Ax-Brach Art                $1,269.21
35021         Dir Rpr Arysm&Grf Insj Innominate Subcla Art       $1,174.29
35022         Dir Rpr Arysm&Grf Rptd Arysm Innom Subcla Art      $1,330.85
35045         Dir Rpr Arysm&Grf Insj Rdl/Ur Art                   $993.14
35081         Dir Rpr Arysm&Grf Insj Abdl Aorta                  $1,621.72
35082         Dir Rpr Arysm&Grf Insj Rptd Arysm Abdl Aorta       $2,195.60
35091         Dir Rpr Arysm&Grf Insj Abdl Aorta Visc Vsl         $2,018.23
35092         Dir Rpr Arysm&Grf Rptd Arysm Abdl Aorta Visc Vsl   $2,535.53
35102         Dir Rpr Arysm&Grf Insj Abdl Aorta Iliac Vsl        $1,768.69
35103         Dir Rpr Arysm&Grf Rptd Arysm Abdl Aorta Iliac      $2,277.25
35111         Dir Rpr Arysm&Grf Insj Splenic Art                 $1,404.45
35112         Dir Rpr Arysm&Grf Insj Rptd Arysm Splenic Art      $1,652.83
35121         Dir Rpr Arysm&Grf Insj Hepatc Celiac Rnl/Msn Art   $1,715.82
35122         Dir Rpr Arysm&Grf Rptd Arysm Hepatc Cel Rnl/Msn    $1,984.83
35131         Dir Rpr Arysm&Grf Insj Iliac Art                   $1,429.69
35132         Dir Rpr Arysm&Grf Insj Rptd Arysm Iliac Art        $1,693.84
35141         Dir Rpr Arysm&Grf Insj Common Fem Art              $1,153.43
35142         Dir Rpr Arysm&Grf Insj Rptd Arysm Common Fem Art   $1,334.48
35151         Dir Rpr Arysm&Grf Insj Pop Art                     $1,305.64
35152         Dir Rpr Arysm&Grf Insj Rptd Arysm Pop Art          $1,467.29
35161         Repair Aneurysm, Other Arteries                    $1,143.57
35162         Repair Ruptr Anrysm, Other Arteries                $1,197.00
35180         Rpr Cgen Arven Fstl Head&Nck                        $833.48
35182         Rpr Cgen Arven Fstl Thorax&Abd                     $1,680.24
35184         Rpr Cgen Arven Fstl Xtr                            $1,041.43
35188         Rpr/Traumtc Arven Fstl Head&Nck                     $887.80

                                           Page 55
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                     Amount
35189         Rpr/Traumtc Arven Fstl Thorax&Abd                             $1,586.33
35190         Rpr/Traumtc Arven Fstl Xtr                                     $777.78
35201         Rpr Blvsl Dir Nck                                              $952.12
35206         Rpr Blvsl Dir Uxtr                                             $786.22
35207         Rpr Blvsl Dir Hand Fngr                                        $709.03
35211         Rpr Blvsl Dir Intrathrc W/Byp                                 $1,354.28
35216         Rpr Blvsl Dir Intrathrc W/O Byp                               $1,135.69
35221         Rpr Blvsl Dir Intra-Abdl                                      $1,361.50
35226         Rpr Blvsl Dir Lxtr                                             $856.35
35231         Rpr Blvsl W/Vein Grf Nck                                      $1,168.56
35236         Rpr Blvsl W/Vein Grf Uxtr                                      $986.63
35241         Rpr Blvsl W/Vein Grf Intrathrc W/Byp                          $1,413.54
35246         Rpr Blvsl W/Vein Grf Intrathrc W/O Byp                        $1,515.45
35251         Rpr Blvsl W/Vein Grf Intra-Abdl                               $1,650.05
35256         Rpr Blvsl W/Vein Grf Lxtr                                     $1,056.93
35261         Rpr Blvsl W/Grf Oth/Thn Vein Nck                              $1,023.37
35266         Rpr Blvsl W/Grf Oth/Thn Vein Uxtr                              $870.73
35271         Rpr Blvsl W/Grf Oth/Thn Vein Intrathrc W/Byp                  $1,347.42
35276         Rpr Blvsl W/Grf Oth/Thn Vein Intrathrc W/O Byp                $1,432.23
35281         Rpr Blvsl W/Grf Oth/Thn Vein Intra-Abdl                       $1,562.55
35286         Rpr Blvsl W/Grf Oth/Thn Vein Lxtr                              $965.88
35301         Teaec W/Patch Grf Crtd Vrt Subcla Nck Inc                     $1,116.95
35311         Teaec +-Patch Grf Subcla Innominate Thrc Inc                  $1,572.26
35321         Teaec +-Patch Grf Ax-Brach                                     $933.98
35331         Teaec +-Patch Grf Abdl Aorta                                  $1,521.73
35341         Teaec +-Patch Grf Mesenteric Celiac/Rnl                       $1,475.25
35351         Teaec +-Patch Grf Iliac                                       $1,321.98
35355         Teaec +-Patch Grf Iliofem                                     $1,074.45
35361         Teaec +-Patch Grf Cmbn Aortoiliac                             $1,611.12
35363         Teaec +-Patch Grf Cmbn Aortoiliofem                           $1,722.85
35371         Teaec +-Patch Grf Common Fem                                   $868.82
35372         Teaec +-Patch Grf Dp Profunda Fem                             $1,041.29
35381         Thromboendarterectomy, With Or Without Patch Graft; Femoral    $964.52
35390         Roprtj Crtd Teaec > 1 Mo After Original Opration               $176.90
35400         Angioscopy Non-C Vsl/Grfs Ther Ivntj                           $169.60
35450         Trluml Balo Angiop Opn Rnl/Oth Visc Art                        $563.87
35452         Trluml Balo Angiop Opn Aortic                                  $410.83
35454         Trluml Balo Angiop Opn Iliac                                   $361.82
35456         Trluml Balo Angiop Opn Fem-Pop                                 $434.48
35458         Trluml Balo Angiop Opn Brch/Cphlc Trnk/Brnch Ea                $553.70
35459         Trluml Balo Angiop Opn Tibioproneal Trnk&Brnch                 $501.98
35460         Trluml Balo Angiop Opn Ven                                     $355.57
35470         Trluml Balo Angiop Prq Tibprnl Trnk/Brnch Ea                   $486.85
35471         Trluml Balo Angiop Prq Rnl/Visc Art                            $562.16
35472         Trluml Balo Angiop Prq Aortic                                  $395.07
35473         Trluml Balo Angiop Prq Iliac                                   $348.46
35474         Trluml Balo Angiop Prq Fempop                                  $399.13
35475         Trluml Balo Angiop Prq Brch/Cphlc Trnk/Brnch Ea                $525.41
35476         Trluml Balo Angiop Prq Ven                                     $342.65
35480         Trluml Prph Athrc Opn Rnl/Oth Visc Art                         $632.99
35481         Trluml Prph Athrc Opn Aortic                                   $451.94
35482         Trluml Prph Athrc Opn Iliac                                    $397.38
35483         Trluml Prph Athrc Opn Fempop                                   $471.21
35484         Trluml Prph Athrc Opn Brch/Cphlc Trnk/Brnch Ea                 $598.87
35485         Trluml Prph Athrc Opn Tibprnl Trnk&Brnch                       $554.31

                                            Page 56
                           MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
35490         Trluml Prph Athrc Prq Rnl/Oth Visc Art                        $611.80
35491         Trluml Prph Athrc Prq Aortic                                  $428.28
35492         Trluml Prph Athrc Prq Iliac                                   $385.57
35493         Trluml Prph Athrc Prq Fempop                                  $464.38
35494         Trluml Prph Athrc Prq Brch/Cphlc Trnk/Brnch Ea                $573.33
35495         Trluml Prph Athrc Prq Tibprnl Trnk&Brnch                      $539.50
35500         Harvest Uxtr Vein 1 Sgm Lxtr/Cab Px                           $345.51
35501         Byp W/Vein Common-Ipsilateral Crtd                           $1,140.50
35506         Byp W/Vein Carotid-Subcla/ Subcla Carotid                    $1,194.93
35507         Bypass Graft, With Vein; Subclavian-Carotid                  $1,190.26
35508         Byp W/Vein Crtd-Vrt                                          $1,156.16
35509         Byp W/Vein Carotid-Contralateral Carotid                     $1,099.09
35510         Byp W/Vein Crtd-Brach                                        $1,314.47
35511         Byp W/Vein Subcla-Subcla                                     $1,218.78
35512         Byp W/Vein Subcla-Brach                                      $1,289.60
35515         Byp W/Vein Subcla-Vrt                                        $1,147.02
35516         Byp W/Vein Subcla-Ax                                          $950.75
35518         Byp W/Vein Ax-Ax                                             $1,207.31
35521         Byp W/Vein Ax-Fem                                            $1,277.72
35522         Byp W/Vein Ax-Brach                                          $1,252.47
35525         Byp W/Vein Brach-Brach                                       $1,196.04
35526         Byp W/Vein Aortosubcla/Crtd                                  $1,682.44
35531         Byp W/Vein Aortoceliac/Aortomesenteric                       $2,023.54
35533         Byp W/Vein Ax-Fem-Fem                                        $1,588.92
35536         Byp W/Vein Splenornl                                         $1,785.04
35541         Bypass Graft, With Vein; Aortoiliac Or Bi-Iliac              $1,506.92
35546         Bypass Graft, With Vein; Aortofemoral Or Bifemoral           $1,490.09
35548         Byp W/Vein Aortoiliofem Uni                                  $1,269.75
35549         Byp W/Vein Aortoiliofem Bi                                   $1,386.76
35551         Byp W/Vein Aortofempop                                       $1,573.11
35556         Byp W/Vein Fempop                                            $1,289.79
35558         Byp W/Vein Fem-Fem                                           $1,218.35
35560         Byp W/Vein Aortornl                                          $1,815.04
35563         Byp W/Vein Ilioiliac                                         $1,370.66
35565         Byp W/Vein Iliofem                                           $1,320.31
35566         Byp Fem-Ant Tibl Pst Tibl Proneal Art/Oth Dstl               $1,569.88
35571         Byp W/Vein Pop-Tibl-Proneal Art/Oth Dstl Vsl                 $1,400.23
35572         Harvest Fempop Vein 1 Sgm Vasc Rcnstj Px                      $370.65
35582         Vein Bypass Graft, Aortofem-Poplit                           $1,588.40
35583         In-Situ Vein Byp Fempop                                      $1,331.07
35585         In-Situ Fem-Ant Tibl Pst Tibl/Proneal Art                    $1,665.89
35587         In-Situ Vein Byp Pop-Tibl Proneal                            $1,450.63
35600         Harvest Uxtr Art 1 Sgm Cab Px                                 $273.27
35601         Byp Oth/Thn Vein Common-Ipsilateral Crtd                     $1,070.66
35606         Byp Oth/Thn Vein Crtd-Subcla                                 $1,134.93
35612         Byp Oth/Thn Vein Subcla-Subcla                                $961.14
35616         Byp Oth/Thn Vein Subcla-Ax                                    $973.04
35621         Byp Oth/Thn Vein Ax-Fem                                      $1,146.30
35623         Byp Oth/Thn Vein Ax-Pop/-Tibl                                $1,373.09
35626         Byp Oth/Thn Vein Aortosubcla/Crtd                            $1,615.94
35631         Byp Oth/Thn Vein Aortoceliac Aortomsn Aortornl               $1,913.23
35636         Byp Oth/Thn Vein Splenornl                                   $1,667.33
35637         Byp Oth/Thn Vein Aortoiliac                                  $1,492.29
35638         Byp Oth/Thn Vein Aortobi-Iliac                                $942.23
35641         Bypass Graft, With Other Than Vein; Aortoiliac Or Bi-Iliac   $1,460.36

                                               Page 57
                           MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                             Amount
35642         Byp Oth/Thn Vein Crtd-Vrt                             $1,078.97
35645         Byp Oth/Thn Vein Subcla-Vrt                           $1,048.22
35646         Byp Oth/Thn Vein Aortobifem                           $1,814.03
35647         Byp Oth/Thn Vein Aortofem                             $1,636.74
35650         Byp Oth/Thn Vein Ax-Ax                                $1,095.61
35651         Byp Oth/Thn Vein Aortofempop                          $1,455.22
35654         Byp Oth/Thn Vein Ax-Fem-Fem                           $1,425.63
35656         Byp Oth/Thn Vein Fempop                               $1,152.24
35661         Byp Oth/Thn Vein Fem-Fem                              $1,109.14
35663         Byp Oth/Thn Vein Ilioiliac                            $1,262.30
35665         Byp Oth/Thn Vein Iliofem                              $1,215.42
35666         Byp Oth/Thn Vein Fem-Ant Tibl Pst Tibl/Proneal        $1,326.29
35671         Byp Oth/Thn Vein Pop-Tibl/-Proneal Art                $1,147.57
35681         Byp Composit Prostc&Vein                                 $88.05
35682         Byp Autog Composit 2 Seg Veins From 2 Locations        $396.79
35683         Byp Autog Composit 3/> Seg From 2/> Locations          $468.36
35685         Plmt Vein Patch/Cuff Dstl Anast Byp Conduit            $212.35
35686         Crtj Dstl Arven Fstl Lxtr Byp Surg Non-Hemo            $176.14
35691         Trpos&/Rimpltj Vrt Crtd Art                           $1,082.31
35693         Trpos&/Rimpltj Vrt Subcla Art                          $944.43
35694         Trpos&/Rimpltj Subcla Crtd Art                        $1,134.36
35695         Trpos&/Rimpltj Crtd Subcla Art                        $1,135.74
35697         Rimpltj Visc Art Infrarnl Aortic Prosth Ea Art         $166.31
35700         Roprtj > 1 Mo After Original Opration                  $170.11
35701         Expl N/Flwd Surg Rpr +-Lss Art Crtd Art                $537.48
35721         Expl N/Flwd Surg Rpr +-Lss Art Fem Art                 $460.20
35741         Expl N/Flwd Surg Rpr +-Lss Art Pop Art                 $499.62
35761         Expl N/Flwd Surg Rpr +-Lss Art Oth Vsl                 $378.05
35800         Expl Po Hemrrg Thrombosis/Infctj Nck                   $471.29
35820         Expl Po Hemrrg Thrombosis/Infctj Ch                    $822.03
35840         Expl Po Hemrrg Thrombosis/Infctj Abd                   $610.41
35860         Expl Po Hemrrg Thrombosis/Infctj Xtr                   $386.03
35870         Rpr Grf-Enteric Fstl                                  $1,306.15
35875         Thrmbc Artl/Ven Grf Oth/Thn Hemo Grf/Fstl              $616.44
35876         Thrmbc Artl/Ven Grf Xcp Hemo Grf/Fstl W/Revj Grf      $1,003.16
35879         Revj Lxtr Artl Byp Opn Vein Patch Angiop               $945.99
35881         Revj Lxtr Artl Byp Opn W/Sgmtl Vein Interpos          $1,061.28
35900         Excision Of Infected Graft;                            $687.44
35901         Exc Infct Grf Nck                                      $545.51
35903         Exc Infct Grf Xtr                                      $620.15
35905         Exc Infct Grf Thorax                                  $1,754.54
35907         Exc Infct Grf Abd                                     $1,926.81
35910         Excision Of Infected Graft; With Revascularization    $1,675.20
36000         Intro Ndl/Intracath Vein                                 $29.04
36001         Introduction Of Needle Or Intracatheter, Vein            $30.25
36002         Njx Px Prq Tx Xtr Pseudoarysm                          $184.33
36005         Njx Px Xtr Vngrph W/Intro Ndl/Intracath                $346.80
36010         Intro Cath Suprior/Ivc                                 $127.31
36011         Slctv Cath Plmt Ven Sys 1St Order Branch               $163.40
36012         Slctv Cath Plmt Ven Sys 2Nd Order/> Slctv Branch       $181.59
36013         Intro Cath R Hrt/Main P-Art                            $126.74
36014         Slctv Cath Plmt L/R P-Art                              $155.83
36015         Slctv Cath Plmt Sgmtl/Subsgmtl P-Art                   $180.78
36100         Intro Ndl/Intracath Crtd/Vrt Art                       $161.88
36101         Introduction Of Needle Or Intracatheter, Carotid Or    $350.90

                                              Page 58
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
36120         Intro Ndl/Intracath Rtrgr Brach Art                             $104.07
36140         Intro Ndl/Intracath Xtr Art                                     $104.12
36145         Intro Ndl/Intracath Arven Shunt Created Dial                    $104.03
36160         Intro Ndl/Intracath Aortic Translmbr                            $134.90
36200         Intro Cath Aorta                                                $157.33
36215         Slctv Cathj Ea 1St Ord Thrc/Brch/Cphlc Brnch                    $243.05
36216         Slctv Cathj 1St 2Nd Ord Thrc/Brch/Cphlc Brnch                   $272.84
36217         Slctv Cathj 3Rd+ Ord Slctv Thrc/Brch/Cphlc Brnch                $328.87
36218         Slctv Cathj Ea 2Nd+ Ord Thrc/Brch/Cphlc Brnch                     $52.93
36230         Selective Catheter Placement, Coronary Artery, Single Or Mul    $302.08
36245         Slctv Cathj Ea 1St Ord Abdl Pel/Lxtr Art Brnch                  $246.01
36246         Slctv Cathj 2Nd Order Abdl Pel/Lxtr Art Brnch                   $274.75
36247         Slctv Cathj 3Rd+ Ord Slctv Abdl Pel/Lxtr Brnch                  $327.41
36248         Slctv Cathj Ea 2Nd+ Ord Abdl Pel/Lxtr Art Brnch                   $53.34
36260         Insj Impltable Ia Nfs Pmp                                       $590.35
36261         Revj Implted Ia Nfs Pmp                                         $361.18
36262         Rmvl Implted Ia Nfs Pmp                                         $272.04
36299         Unlis Px Vasc Njx                                                  $0.00
36400         Vnpnxr <3 Years Phys Skill Fem/Jug Vein                           $25.18
36405         Vnpnxr <3 Years Phys Skill Scalp Vein                             $21.84
36406         Vnpnxr <3 Years Phys Skill Other Vein                             $18.08
36410         Vnpnxr 3 Years/> Phys Skill                                       $18.08
36415         Collj Ven Bld Vnpnxr                                               $3.00
36416         Collj Capillary Bld Spec                                           $0.00
36420         Vnpnxr Cutdown Under Age 1 Yr                                   $153.93
36425         Vnpnxr Cutdown Age 1/>                                            $38.85
36430         Transfusion Bld/Bld Components                                    $39.32
36431         Transfusion, Blood Or Blood Components;                           $90.75
36440         Push Transfusion Bld 2 Yr/Under                                   $53.48
36450         Exchng Transfusion Bld Nb                                       $116.92
36455         Exchng Transfusion Bld Oth/Thn Nb                               $132.86
36460         Transfusion Intrauterine Ftl                                    $355.52
36468         1/Mlt Njxs Sclrsg Slns Spider Veins Limb/Trnk                      $0.00
36469         1/Mlt Njxs Sclrsg Slns Spider Veins Face                           $0.00
36470         Njx Sclrsg Sln 1 Vein                                           $144.90
36471         Njx Sclrsg Sln Mlt Veins Sm Leg                                 $178.05
36475         Endoven Abltj Incmptnt Vein Xtr Rf 1St Vein                    $2,188.00
36476         Endoven Abltj Incmptnt Vein Xtr Rf 2Nd+ Veins                   $429.54
36478         Endoven Abltj Incmptnt Vein Xtr Laser 1St Vein                 $2,015.54
36479         Endoven Abltj Incmptnt Vein Xtr Laser 2Nd+ Veins                $433.64
36480         Cathrzatn Subclav Exter Juglr Percutaneous                        $86.50
36481         Prq Portal Vein Cathj Any Meth                                  $554.38
36485         Cathrzatn Subclau Exter Juglr;By Cutdown                          $72.60
36495         Insertion Of Implantable Intravenous Infusion Pump Or Venous    $577.60
36496         Revision Of Implantable Intravenous Infusion Pump Or Venous     $326.30
36497         Removal Of Implantable Intravenous Infusion Pump Or Venous A    $208.80
36500         Ven Cathj Slctv Organ Bld Sampling                              $188.00
36510         Cathj Umbilical Vein Dx/Ther Nb                                 $180.12
36511         Ther Apheresis White Bld Cells                                    $93.74
36512         Ther Apheresis Red Bld Cells                                      $93.74
36513         Ther Apheresis Pltlts                                             $93.74
36514         Ther Apheresis Plsm Pheresis                                      $93.74
36515         Ther Apheresis W/Xtrcorp Immunodsptj&Plsm Renfs                   $94.47
36516         Ther Aphrs Xtrcorp Slctv Adsrpj/Filtrj&Renfs                      $67.02
36520         Plasma And/Or Cell Exchange                                     $115.44

                                            Page 59
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                          Amount
36521         Apheresis W/ Adsorp/Reinfuse                        $105.37
36522         Photopheresis Xtrcorp                               $296.76
36540         Collj Bld Spec From Complly Impltable Vad              $0.00
36550         Decltng Thrombolytic Agt Implted Vasc Access Dev      $29.30
36555         Insj Non-Tun Ctr Cvc Under 5 Yr                     $327.71
36556         Insj Non-Tun Ctr Cvc Age 5 Yr/>                     $311.03
36557         Insj Tun Ctr Cvc W/O Subq Port/Pmp Under 5 Yr       $709.22
36558         Insj Tun Ctr Cvc W/O Subq Port/Pmp Age 5 Yr/>       $694.00
36560         Insj Tun Ctr Ctr Vad W/Subq Port Under 5 Yr        $1,322.90
36561         Insj Tun Ctr Ctr Vad W/Subq Port Age 5 Yr/>        $1,310.64
36563         Insj Tun Ctr Ctr Vad W/Subq Pmp                    $1,649.69
36565         Insj Tun Vad Req 2 Cath 2 Sits W/O Subq Port/Pmp   $1,056.49
36566         Insj Tun Vad Req 2 Cath 2 Sits W/Subq Port         $1,104.37
36568         Insj Prph Cvc W/O Subq Port/Pmp Under 5 Yr          $379.30
36569         Insj Prph Cvc W/O Subq Port/Pmp Age 5 Yr/>          $344.32
36570         Insj Prph Ctr Vad W/Subq Port Under 5 Yr           $1,692.77
36571         Insj Prph Ctr Vad W/Subq Port Age 5 Yr/>           $1,522.96
36575         Rpr Tun/Non-Tun Ctr Vad Cath W/O Subq Port/Pmp      $171.36
36576         Rpr Ctr Vad W/Subq Port/Pmp Ctr/Prph Insj Sit       $424.66
36578         Rplcmt Cath Ctr Vad Subq Port/Pmp                   $539.20
36580         Rplcmt Compl Non-Tun Cvc W/O Subq Port/Pmp          $302.27
36581         Rplcmt Compl Tun Cvc W/O Subq Port/Pmp              $636.65
36582         Rplcmt Compl Tun Ctr Vad W/Subq Port               $1,190.21
36583         Rplcmt Compl Tun Ctr Vad W/Subq Pmp                 $699.11
36584         Rplcmt Compl Prph Cvc W/O Subq Port/Pmp             $315.33
36585         Rplcmt Compl Prph Ctr Vad W/Subq Port              $1,497.71
36589         Rmvl Tun Cvc W/O Subq Port/Pmp                      $175.27
36590         Rmvl Tun Ctr Vad W/Subq Port/Pmp Ctr/Prph Insj      $373.97
36595         Mchnl Rmvl Pricath Obstr Cv Dev Via Ven Access      $865.17
36596         Mchnl Rmvl Intral Obstr Cv Dev Thru Dev Lumen       $190.34
36597         Rpsg Previously Placed Cvc Under Fluor Gdn          $164.15
36598         Cntrst Njx Rad Eval Ctr Vad Fluor Img&Reprt         $129.69
36600         Artl Pnxr W/Drawal Bld Dx                             $30.29
36620         Artl Cathj/Cannulj Mntr/Transfusion Spx Prq           $54.55
36625         Artl Cathj/Cannulj Mntr/Transfusion Spx Cutdown     $105.50
36640         Artl Cathj Prolng Nfs Ther Chemotx Cutdown          $125.70
36660         Cathj Umbilical Art Nb Dx/Ther                        $72.41
36680         Plmt Ndl Intraoss Nfs                                 $66.77
36800         Insj Cannula Hemo Oth Purpose Spx Vein Vein         $165.37
36810         Insj Cannula Hemo Oth Purpose Spx Arven Xtrnl       $229.10
36815         Insj Cannula Hemo Oth Spx Arven Xtrnl Revj/Clsr     $153.16
36818         Arven Anast Opn Upr Arm Cephalic Vein Trpos         $737.84
36819         Arven Anast Opn Upr Arm Basilic Vein Trpos          $832.19
36820         Arven Anast Opn F/Arm Vein Trpos                    $832.19
36821         Hemodialysis Access By Joining Artery And Vein      $552.66
36822         Insj Cannula Prolng Xc-Circj Ecmo Spx               $396.88
36823         Insj Cnula Isltd Xc-Circj Reg Chemotx Xtr Rmvl     $1,236.17
36825         Crtj Arven Fstl Xcp Dir Arven Anast Autog Grf       $608.03
36830         Crtj Arven Fstl Xcp Dir Arven Anast Nonautog Grf    $705.55
36831         Thrmbc Opn Arven Fstl W/O Revj Dial Grf             $481.96
36832         Revj Opn Arven Fstl W/O Thrmbc Dial Grf             $621.56
36833         Revj Opn Arven Fstl W/Thrmbc Dial Grf               $700.63
36834         Plstc Rpr Arven Arysm Spx                           $598.12
36835         Insj Thomas Shunt Spx                               $465.96
36838         Dstl Revsc&Interval Lig Uxtr Hemo Access           $1,232.63

                                           Page 60
                           MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                 Amount
36840         Insertion Mandril                                          $399.30
36845         Anastomosis Mandril                                        $810.70
36860         Xtrnl Cannula Decltng Spx W/O Balo Cath                    $170.86
36861         Xtrnl Cannula Decltng Spx W/Balo Cath                      $155.05
36870         Thrmbc Prq Arven Fstl Autog/Nonautog Grf                  $1,919.20
37140         Ven Anast Opn Portocaval                                  $1,322.51
37145         Ven Anast Opn Renoportal                                  $1,438.19
37160         Ven Anast Opn Caval-Mesenteric                            $1,251.19
37180         Ven Anast Opn Splenornl Prox                              $1,424.33
37181         Ven Anast Opn Splenornl Dstl                              $1,529.58
37182         Insj Transvns Intrahepatc Portosysic Shunt                 $935.83
37183         Revj Transvns Intrahepatc Portosysic Shunt                 $431.96
37184         Prim Prq Trluml Mchnl Thrmbc 1St Vsl                      $3,053.51
37185         Prim Prq Trluml Mchnl Thrmbc Sbsq Vsl                      $995.60
37186         Sec Prq Trluml Thrmbc                                     $2,061.47
37187         Prq Trluml Mchnl Thrmbc Vein                              $2,970.87
37188         Prq Trluml Mchnl Thrmbc Vein Repeat Tx                    $2,567.87
37190         Plastic Repair Of Arteriovenous Aneurysm                   $738.71
37195         Thrombolss Cere Iv Nfs                                     $313.77
37200         Tcat Bx                                                    $234.02
37201         Tcat Ther Nfs Thrombolss Oth/Thn C                         $290.14
37202         Tcat Ther Nfs Oth/Thn Thrombolss Any Typ                   $341.07
37203         Tcat Retrieval Prq Iv Fb                                   $291.21
37204         Tcat Occls/Embolj Prq Non-Cns Non-Head/Nck                 $937.49
37205         Tcat Plmt Iv Stent Xcp C Crtd&Vrt Prq 1St Vsl               $466.51
37206         Tcat Plmt An Iv Stent Xcp C Crtd&Vrt Prq Ea                 $217.40
37207         Tcat Plmt An Iv Stent Non-C Vsl Opn 1St Vsl                $468.08
37208         Tcat Plmt An Iv Stent Non-C Vsl Opn Ea Vsl                 $226.16
37209         Exchng Prev Placed Iv Cath Thrombolytic Ther               $117.43
37215         Tcat Iv Stent Crv Crtd Art Embolic Protecj                $1,092.54
37216         Tcat Iv Stent Crv Crtd Art W/O Embolic Protecj            $1,052.40
37250         Iv Us Non-C Vsl Dx Eval&/Ther Ivntj 1St Vsl                $114.34
37251         Iv Us Non-C Vsl Dx Eval&/Ther Ivntj Ea Vsl                   $86.74
37400         Arteriorrhaphy, Suture Of Major Artery, Wound Or Injury   $1,210.00
37420         Arteriorrhaphy, Suture Of Major Artery, Wound Or Injury   $1,936.00
37440         Arteriorrhaphy, Suture Of Major Artery, Wound Or Injury   $1,936.00
37460         Arteriorrhaphy, Suture Of Major Artery, Wound Or Injury    $968.00
37470         Repair Multiple Arteries And/Or Veins                     $1,936.00
37500         Vasc Ndsc Seps                                             $689.49
37501         Unlis Vasc Ndsc Px                                            $0.00
37520         Phleborrhaphy, Suture Of Major Vein, Wound Or Injury      $1,936.00
37540         Phleborrhaphy, Suture Of Major Vein, Wound Or Injury      $1,936.00
37560         Phleborrhaphy, Suture Of Major Vein, Wound Or Injury       $726.00
37565         Lig Int Jug Vein                                           $633.78
37600         Lig Xtrnl Crtd Art                                         $682.40
37605         Lig Int/Common Crtd Art                                    $780.02
37606         Lig Int/Common Crtd Art W/Gradual Occls                    $440.38
37607         Lig/Banding Angioaccess Arven Fstl                         $393.68
37609         Lig/Bx Temporal Art                                        $293.81
37615         Lig Major Art Nck                                          $392.10
37616         Lig Major Art Ch                                          $1,007.38
37617         Lig Major Art Abd                                         $1,242.24
37618         Lig Major Art Xtr                                          $337.89
37620         Interrupj Ivc Sutr Lig Plctj Clip Xtrvasc Iv               $639.04
37650         Lig Fem Vein                                               $490.89

                                              Page 61
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
37651         Interruption, Partial Or Complete, Of Femoral Vein, By Ligat    $726.00
37660         Lig Common Iliac Vein                                          $1,172.64
37700         Lig&Div Long Saph Vein Saphfem Junct/Interrupj                  $261.04
37701         Ligation And Division Of Long Saphenous Vein At Saphenofemor    $302.50
37718         Lig Div&Stripping Short Saphenous Vein                          $414.87
37720         Ligation And Division And Complete Stripping Of Long Or Shor    $377.28
37721         Ligation And Division And Complete Stripping Of Long Or Shor    $726.00
37722         Lig Div&Strip Long Saph Saphfem Junct Kne/Belw                  $496.23
37730         Ligation And Division And Complete Stripping Of Long And Sho    $467.45
37731         Ligation And Division And Complete Stripping Of Long And Sho    $907.50
37735         Lig&Div&Compl Strip Long/Short Saph Rad Exc                     $652.10
37737         Ligation And Division And Complete Stripping Of Long Or Shor    $508.20
37760         Lig Prforator Veins Subfscal Rad +-Skn Grf Opn                  $641.17
37765         Stab Phlebt Varicose Veins 1 Xtr 10-20 Stab Incs                $459.74
37766         Stab Phlebt Varicose Veins 1 Xtr > 20 Incs                      $558.47
37780         Lig&Div Short Saph Vein Saphenopop Junct Spx                    $268.11
37781         Ligation And Division Of Short Saphenous Vein At Saphenopopl    $314.60
37785         Lig Div&/Exc Varicose Vein Cluster 1 Leg                        $350.64
37787         Ligation, Division, And/Or Excision Of Secondary Varicose         $90.75
37788         Pen Revsc Art +-Vein Grf                                       $1,226.25
37790         Pen Ven Occlusive Px                                            $507.37
37799         Unlis Px Vasc Surg                                                 $0.00
38090         Puncture Spleen                                                 $605.00
38100         Splenc Tot Spx                                                  $832.04
38101         Splenc Prtl Spx                                                 $878.72
38102         Splenc Tot En Bloc X10Sv Ds Conjunct W/Oth Px                   $263.11
38115         Rpr Rptd Spleen Splenorrhaphy +-Prtl Splenc                     $903.37
38120         Laps Surg Splenc                                                $989.99
38129         Unlis Laps Px Spleen                                               $0.00
38200         Njx Px Splenoportograpy                                         $136.77
38204         Mgmt Rcp Hematop Progenitor Cell Don Search&Cell                   $0.00
38205         Bld-Drv Hematop Progen Cell Hrvg Trnsplj Algnc                    $82.91
38206         Bld-Drv Hematop Progen Cell Hrvg Trnsplj Autol                    $82.91
38207         Trnspl Prepj Hematop Progen Cells Cryoprsrv&Strg                   $0.00
38208         Trnspl Prepj Hematop Progen Thaw Prev Hrv                          $0.00
38209         Trnspl Prepj Hematop Progen Thaw Prev Hrv Washg                    $0.00
38210         Trnspl Prepj Hematop Progen Deplj In Hrv T-Cell                    $0.00
38211         Trnspl Prepj Hematop Progen Tum Cell Deplj                         $0.00
38212         Trnspl Prepj Hematop Progen Red Bld Cell Rmvl                      $0.00
38213         Trnspl Prepj Hematop Progen Pltlt Deplj                            $0.00
38214         Trnspl Prepj Hematop Progen Plsm Vol Deplj                         $0.00
38215         Trnspl Prepj Hematop Progen Concentration Plsm                     $0.00
38220         Marrow Aspiration Only                                          $187.29
38221         Marrow Bx Ndl/Trocar                                            $206.19
38230         Marrow Hrvg Trnsplj                                             $293.82
38231         Stem Cell Collection                                              $89.83
38240         Marrow/Bld-Drv Prph Stem Cell Trnsplj Allogenic                 $125.32
38241         Marrow/Bld-Drv Prph Stem Cell Trnsplj Autol                     $125.68
38242         Marrow/Bld-Drv Prph Stem Cell Trnsplj Algc Don                    $94.41
38300         Drg Lymph Node Absc/Lymphadenitis Smpl                          $243.03
38305         Drg Lymph Node Absc/Lymphadenitis X10Sv                         $459.52
38308         Lymphangiotomy/Oth Oprations Lymphatic Channels                 $474.19
38380         Sutr&/Lig Thrc Dux Crv Appr                                     $520.04
38381         Sutr&/Lig Thrc Dux Thrc Appr                                    $811.31
38382         Sutr&/Lig Thrc Dux Abdl Appr                                    $641.41

                                            Page 62
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
38500         Bx/Exc Lymph Node Opn Supfc                                     $291.51
38505         Bx/Exc Lymph Node Ndl Supfc                                     $124.82
38510         Bx/Exc Lymph Node Opn Dp Crv Node                               $464.74
38520         Bx/Exc Lymph Node Opn Dp Crv Node W/Exc Fat Pad                 $424.39
38525         Bx/Exc Lymph Node Opn Dp Ax Node                                $372.56
38530         Bx/Exc Lymph Node Opn Int Mam Node                              $491.37
38540         Dissection; Deep Cervic Node                                    $484.00
38542         Dsj Dp Jug Node                                                 $409.40
38550         Exc Cstic Hygroma Ax/Crv W/O Dp Neurovasc Dsj                   $437.48
38555         Exc Cstic Hygroma Ax/Crv W/Dp Neurovasc Dsj                     $913.60
38562         Lmtd Lmphadec Staging Spx Pel&Para-Aortic                       $651.43
38564         Lmtd Lmphadec Staging Spx Rpr Aortic&/Splenic                   $649.25
38570         Laps Surg Rpr Lymph Node Bx 1/Mlt                               $532.42
38571         Laps Surg Bi Tot Pel Lmphadec                                   $790.93
38572         Laps Bi Tot Pel Lmphadec&Pri-Aortic Lymph Bx 1/+                $940.46
38589         Unlis Laps Px Lymphatic Sys                                        $0.00
38700         Suprahyoid Lmphadec                                             $632.00
38701         Suprahyoid Lymphadenectomy                                     $1,185.80
38720         Crv Lmphadec Compl                                              $962.11
38721         Cervical Lymphadenectomy (Complete)                            $1,512.50
38724         Crv Lmphadec Modf Rad Nck Dsj                                  $1,018.76
38740         Ax Lmphadec Supfc                                               $590.47
38745         Ax Lmphadec Compl                                               $758.77
38746         Thrc Lmphadec Regional W/Medstnl&Pritracheal Nod                $268.22
38747         Abdl Lmphadec Reg Celiac Gstr Portal Pripncrtc                  $267.97
38760         Inguinofem Lmphadec Supfc W/Cloquets Node Spx                   $752.31
38761         Inguinofemoral Lymphadenectomy, Superficial,                   $1,210.00
38765         Inguinofem Lmphadec Supfc W/Pel Lmphadec                       $1,144.27
38766         Inguinofemoral Lymphadenectomy, Superficial, In                $1,996.50
38770         Pel Lmphadec W/Xtrnl Iliac Hypogstr&Obturator                   $753.82
38771         Pelvic Lymphadenectomy, Including External Iliac,              $1,633.50
38780         Rpr Tabdl Lmphadec X10Sv W/Pel Aortic&Rnl                       $999.21
38790         Njx Px Lymphangrph                                              $463.08
38791         Injection Procedure For Lymphangiography                        $314.60
38792         Njx Id Sentinel Node                                              $37.52
38794         Cannulation Thrc Dux                                            $298.48
38999         Unlis Px Hemic/Lymphatic Sys                                       $0.00
39000         Mediast W/Expl Drg Rmvl Fb/Bx Crv Appr                          $434.82
39010         Mediast W/Expl Drg Rmvl Fb/Bx Tthrc Appr                         $754.65
39020         Mediastinotomy With Exploration, Drainage, Or Removal Of For    $892.76
39200         Exc Medstnl Cst                                                 $837.82
39220         Exc Medstnl Tum                                                $1,064.47
39400         Mediastinoscopy +-Bx                                            $420.70
39499         Unlis Px Med                                                       $0.00
39500         Diaphragmatc Hernia Repair Incl Fundplsty                      $1,391.50
39501         Rpr Lac Dphrm Any Appr                                          $797.38
39502         Rpr Paraesophgl Hiatus Hrna Tabdl                               $954.50
39503         Rpr Neonatal Diphrg Hrna +-Ch Tube Insj                        $4,940.27
39510         Repair Of Diaphragm Hernia                                     $1,694.00
39520         Rpr Diphrg Hrna Esophgl Hiatal Tthrc                            $986.47
39530         Rpr Diphrg Hrna Cmbn Thoracoabdl                                $918.93
39531         Rpr Diphrg Hrna Cmbn Thoracoabdl W/Dilat Strix                  $974.32
39540         Rpr Diphrg Hrna Oth/Thn Neonatal Traumtc Aqt                    $793.83
39541         Rpr Diphrg Hrna Oth/Thn Neonatal Traumtc Chrnc                  $854.59
39545         Imbrcj Of Diaphragm                                             $852.81

                                            Page 63
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                Amount
39547         Imbrication Of Diaphragm For Eventration; Nonparalytic    $812.62
39560         Rescj Dphrm Smpl Rpr                                      $745.52
39561         Rescj Dphrm Cplx Rpr                                     $1,092.40
39599         Unlis Px Dphrm                                               $0.00
40490         Bx Lip                                                    $115.96
40500         Vermilionectomy Lip Shv W/Mucosal Advmnt                  $396.51
40510         Exc Lip Transvrs Wedge Exc W/Prim Clsr                    $442.87
40520         Exc Lip V-Exc W/Prim Dir Linr Clsr                        $462.41
40525         Exc Lip Full Thkns Rcnstj W/Local Flap                    $566.86
40527         Exc Lip Full Thkns Rcnstj W/Cross Lip Flap                $667.46
40530         Rescj Lip > One-4Th W/O Rcnstj                            $464.36
40650         Rpr Lip Full Thkns Vermilion Only                         $353.26
40652         Rpr Lip Full Thkns Up Half Ver H8                         $415.17
40654         Rpr Lip Full Thkns > One-Half Ver H8/Cplx                 $482.95
40700         Plstc Rpr Cl Lip/Nsl Dfrm Prim Prtl/Compl Uni             $869.65
40701         Plstc Rpr Cl Lip/Nsl Dfrm Prim Bi 1 Stg Px               $1,088.32
40702         Plstc Rpr Cl Lip/Nsl Dfrm Prim Bi 1 2 Stgs                $845.07
40720         Plstc Rpr Cl Lip/Nsl Dfrm Sec Recrtj Dfct&Reclsr          $952.90
40740         Plastic Repair Of Cleft Lip                              $1,064.80
40761         Plstc Rpr Cl Lip/Nsl Dfrm W/Cross Lip Pedcl Flap         $1,013.15
40799         Unlis Px Lips                                                $0.00
40800         Drg Absc Cst Hmtma Vestibule Mouth Smpl                   $128.86
40801         Drg Absc Cst Hmtma Vestibule Mouth Comp                   $219.17
40804         Rmvl Embedded Fb Vestibule Mouth Smpl                     $143.89
40805         Rmvl Embedded Fb Vestibule Mouth Comp                     $232.77
40806         Inc Labial Frenum Frexomy                                   $62.42
40808         Bx Vestibule Mouth                                        $122.72
40810         Exc Les Mucosa&Sbmcsl Vestibule Mouth W/O Rpr             $140.30
40812         Exc Les Mucosa&Sbmcsl Vestibule Smpl Rpr                  $213.11
40814         Exc Les Mucosa&Sbmcsl Vestibule Cplx Rpr                  $313.02
40816         Exc Les Mucosa&Sbmcsl Vestibule Cplx Exc Musc             $329.38
40818         Exc Mucosa Vestibule Mouth As Don Grf                     $285.32
40819         Exc Frenum Labial/Buccal                                  $258.47
40820         Dstrj Les/Scar Vestibule Mouth Physical Meths             $150.09
40830         Clsr Lac Vestibule Mouth 2.5 Cm/<                         $184.74
40831         Clsr Lac Vestibule Mouth >2.5 Cm/Cplx                     $233.85
40840         Vestibuloplasty Ant                                       $677.55
40842         Vestibuloplasty Pst Uni                                   $674.29
40843         Vestibuloplasty Pst Bi                                    $889.07
40844         Vestibuloplasty Entire Arch                              $1,181.85
40845         Vestibuloplasty Cplx W/Ridge Xtn Musc Rpsg               $1,342.33
40899         Unlis Px Vestibule Mouth                                     $0.00
41000         Intraoral I&D Tongue/Floor Lngl                           $143.21
41005         Intraoral I&D Tongue/Floor Sublngl Supfc                  $149.02
41006         Intraoral I&D Tongue/Floor Sublngl Dp Sprmlhyd            $293.12
41007         Intraoral I&D Tongue/Floor Submental Space                $278.64
41008         Intraoral I&D Tongue/Floor Submndblr Space                $302.67
41009         Intraoral I&D Tongue/Floor Masticator Space               $323.34
41010         Inc Lngl Frenum Frexomy                                   $168.77
41015         Xtroral I&D Absc Cst/Hmtma Floor Mouth Sublngl            $357.45
41016         Xtroral I&D Absc Cst/Hmtma Floor Mouth Submental          $364.44
41017         Xtroral I&D Absc Cst/Hmtma Floor Mouth Submndblr          $363.19
41018         Xtroral I&D Floor Masticator Space                        $418.93
41100         Bx Tongue Ant 2-3Rd                                       $160.04
41105         Bx Tongue Pst One-3Rd                                     $147.73

                                             Page 64
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                          Amount
41108         Bx Floor Mouth                                      $123.61
41110         Exc Les Tongue W/O Clsr                             $153.69
41112         Exc Les Tongue W/Clsr Ant 2-3Rd                     $266.89
41113         Exc Les Tongue W/Clsr Pst One-3Rd                   $298.48
41114         Exc Les Tongue W/Clsr W/Local Tongue Flap           $666.73
41115         Exc Lngl Frenum Frenectomy                          $196.73
41116         Exc Les Floor Mouth                                 $253.75
41120         Glssc < One-Half Tongue                             $675.39
41130         Glssc Hemiglssc                                     $760.72
41135         Glssc Prtl W/Uni Rad Nck Dsj                       $1,483.93
41140         Glssc Compl/Tot +-Trachs W/O Rad Nck Dsj           $1,627.81
41145         Glssc Compl/Tot +-Trachs W/Uni Rad Nck Dsj         $1,924.24
41150         Glssc Composit W/Rescj Floor&Mndblr Rescj          $1,506.57
41153         Glssc Composit Rescj Floor Suprahyoid Nck Dsj      $1,552.65
41155         Glssc Composit Rescj Flr Mndblr Rescj&Rad Nck      $1,789.72
41250         Rpr Lac 2.5 Cm/< Floor Mouth&/Ant 2-3Rd Tongue      $190.74
41251         Rpr Lac 2.5 Cm/< Pst One-3Rd Tongue                 $224.44
41252         Rpr Lac Tongue Floor Mouth > 2.6 Cm/Cplx            $274.19
41500         Fixj Tongue Mchnl Oth/Thn Sutr                      $283.32
41510         Sutr Tongue Lip Micrognathia                        $252.32
41520         Frenoplasty Surg Revj Frenum Eg W/Z-Plasty          $259.91
41599         Unlis Px Tongue Floor Mouth                            $0.00
41800         Drg Absc Cst Hmtma From Dentoalveolar Struxs        $145.29
41805         Rmvl Embedded Fb From Dentalvlr Struxs Soft Tiss    $150.46
41806         Rmvl Embedded Fb From Dentoalveolar Struxs B1       $243.61
41820         Gingivectomy Exc Gingiva Ea Quadrant                   $0.00
41821         Oprculectomy Exc Pricoronal Tiss                       $0.00
41822         Exc Fibrous Tuberosities Dentoalveolar Struxs       $247.40
41823         Exc Oss Tuberosities Dentoalveolar Struxs           $349.98
41825         Exc Les/Tum Xcp Listed Above Dentalvlr              $173.20
41826         Exc Les/Tum Xcp Listed Above Dentalvlr Smpl Rpr     $235.38
41827         Exc Les/Tum Xcp Listed Above Dentalvlr Cplx Rpr     $344.38
41828         Exc Hyprplstc Alveolar Mucosa Ea Quadrant Spec      $286.30
41830         Alveolectomy W/Curtg Osteitis/Sequestrectomy        $315.40
41850         Dstrj Les Xcp Exc Dentoalveolar Struxs                 $0.00
41870         Pdontal Mucosal Grfg                                   $0.00
41872         Gingivoplasty Ea Quadrant Spec                      $274.73
41874         Alveoloplasty Ea Quadrant Spec                      $297.66
41899         Unlis Px Dentoalveolar Struxs                          $0.00
42000         Drg Absc Palate Uvula                               $150.13
42100         Bx Palate Uvula                                     $136.69
42104         Exc Les Palate Uvula W/O Clsr                       $167.72
42106         Exc Les Palate Uvula W/Smpl Prim Clsr               $221.98
42107         Exc Les Palate Uvula W/Local Flap Clsr              $402.93
42120         Rescj Palate/X10Sv Rescj Les                        $454.60
42140         Uvulectomy Exc Uvula                                $156.74
42145         Palatopharyngoplasty                                $569.24
42150         Removal Of Exostosis, Bony Palate                   $130.38
42160         Dstrj Les Palate/Uvula Thermal Cryo/Chem            $204.81
42180         Rpr Lac Palate Up 2 Cm                              $226.13
42182         Rpr Lac Palate >2 Cm/Cplx                           $310.52
42200         Palatop Cl Palate Soft&/Hard Palate Only            $823.93
42205         Palatop W/Clsr Alveolar Ridge Soft Tiss             $877.18
42210         Palatop Clsr Alveolar Ridge Grf Alveolar Ridge      $985.84
42215         Palatop Cl Palate Major Revj                        $651.85

                                            Page 65
                           MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
42220         Palatop Cl Palate Sec Lngth Px                                  $487.63
42225         Palatop Cl Palate Attachment Pharyngeal Flap                    $672.17
42226         Lngth Palate&Pharyngeal Flap                                    $696.56
42227         Lngth Palate W/Island Flap                                      $657.29
42235         Rpr Ant Palate W/Vomer Flap                                     $512.84
42260         Rpr Nasolabial Fstl                                             $744.49
42280         Max Impresj Palatal Prosth                                      $136.23
42281         Insj Pin-Retained Palatal Prosth                                $185.61
42299         Unlis Px Palate Uvula                                              $0.00
42300         Drg Absc Prtd Smpl                                              $187.11
42305         Drg Absc Prtd Comp                                              $429.40
42310         Drg Absc Submax/Sublngl Intraoral                               $148.98
42320         Drg Absc Submax Xtrnl                                           $224.83
42325         Fistulization Of Sublingual Salivary Cyst (Ranula);             $240.49
42326         Fistulization Of Sublingual Salivary Cyst (Ranula); With Pro    $323.23
42330         Sialot Submndblr Sublngl/Prtd Uncomp Intraoral                  $210.75
42335         Sialolithotomy Submndblr Submax Comp Intraoral                  $277.39
42340         Sialolithotomy Prtd Xtroral/Comp Intraoral                      $375.76
42400         Bx Salivary Glnd Ndl                                              $95.87
42405         Bx Salivary Glnd Incal                                          $286.91
42408         Exc Sublngl Salivary Cst Ranula                                 $370.23
42409         Marsupialization Sublngl Salivary Cst Ranula                    $244.32
42410         Exc Prtd Tum/Prtd Glnd Lat Lobe W/O Nrv Dsj                     $628.67
42415         Exc Prtd Tum/Prtd Glnd Lat Dsj&Prsrv Facial Nrv                $1,102.54
42420         Exc Prtd Tum/Prtd Glnd Tot Dsj&Prsrv Facial Nrv                $1,267.85
42425         Exc Prtd Tum/Prtd Glnd Tot En Bloc Rmvl                         $864.61
42426         Exc Prtd Tum/Prtd Glnd Tot W/Uni Rad Nck Dsj                   $1,360.00
42440         Exc Submndblr Submax Glnd                                       $469.87
42450         Exc Sublngl Glnd                                                $395.49
42500         Plstc Rpr Salivary Dux Sialodochoplasty Prim                    $374.21
42505         Plstc Rpr Salivary Dux Sialodochoplasty Sec/Comp                $503.90
42507         Prtd Dux Dvrj Bi                                                $450.20
42508         Prtd Dux Dvrj Bi W/Exc 1 Submndblr Glnd                         $627.08
42509         Prtd Dux Dvrj Bi W/Exc Bth Submndblr Glnds                      $798.64
42510         Parotid Duct Dvrj Bilateral With Lig Both Ducts                 $555.12
42550         Njx Sialograpy                                                  $526.05
42600         Clsr Salivary Fstl                                              $409.17
42650         Dilat Salivary Dux                                                $74.32
42660         Dilat&Cathj Salivary Dux +-Njx                                    $99.49
42665         Lig Salivary Dux Intraoral                                      $233.01
42699         Unlis Px Salivary Glnds/Duxs                                       $0.00
42700         I&D Absc Pritonsillar                                           $166.24
42720         I&D Absc Rtrphrngl/Parapharyngeal Intraoral                     $405.16
42725         I&D Absc Rtrphrngl/Parapharyngeal Xtrnl Appr                    $730.71
42800         Bx Oropharynx                                                   $138.21
42802         Bx Hypopharynx                                                  $222.73
42804         Bx Nasopharynx Visible Les Smpl                                 $195.74
42806         Bx Nasopharynx Surv Unknown Prim Les                            $214.77
42808         Exc/Dstrj Les Pharynx Any Meth                                  $210.18
42809         Rmvl Fb From Pharynx                                            $160.27
42810         Exc Branchial Cl Cst Confined Skn&Subq Tiss                     $310.29
42815         Exc Branchial Cl Cst Extg Belw Subq Tiss&/Phrnx                 $487.57
42820         Tonsillectomy&Adenoidectomy Under Age 12                        $286.16
42821         Tonsillectomy&Adenoidectomy Age 12/>                            $308.83
42825         Tonsillectomy 1/2 Under Age 12                                  $260.36

                                               Page 66
                         MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
42826         Tonsillectomy 1/2 Age 12/>                                      $254.44
42830         Adenoidectomy Prim Under Age 12                                 $200.58
42831         Adenoidectomy Prim Age 12/>                                     $214.98
42835         Adenoidectomy Sec Under Age 12                                  $190.09
42836         Adenoidectomy Sec Age 12/>                                      $244.38
42842         Rad Rescj Tonsil W/O Clsr                                       $602.94
42844         Rad Rescj Tonsil Clsr W/Local Flap                              $950.68
42845         Rad Rescj Tonsil Clsr W/Oth Flap                               $1,579.98
42860         Exc Tonsil Tags                                                  $184.83
42870         Exc/Dstrj Lngl Tonsil Any Meth Spx                              $394.88
42880         Excision Nasopharyngeal Lesion (Eg, Fibroma)                    $459.60
42890         Lmtd Pharyngectomy                                              $868.23
42892         Rescj Lat Phrngl Wall/Pyriform Sinus Dir Clsr                  $1,043.72
42894         Rescj Pharyngeal Wall Req Clsr W/Myoq Flap                     $1,484.04
42895         Throat And Neck Surgery                                         $798.60
42900         Sutr Pharynx Wnd/Inj                                             $349.89
42950         Pharyngoplasty Plstc/Rcnstv Opration Pharynx                    $571.55
42953         Pharyngoesophgl Rpr                                             $644.95
42955         Pharyngostomy Fstlj Pharynx Xtrnl Feeding                       $510.24
42960         Ctrl Oropharyngeal Hemrrg 1/2 Smpl                              $168.57
42961         Ctrl Oropharyngeal Hemrrg 1/2 Comp Req Hospitj                  $404.98
42962         Ctrl Oropharyngeal Hemrrg 1/2 W/Sec Surg Ivntj                  $500.68
42970         Ctrl Nasphryngl Hemrrg 1/2 Smpl W/Pst Nsl Packs                 $352.51
42971         Ctrl Nasphryngl Hemrrg 1/2 Comp Req Hospization                 $434.95
42972         Ctrl Nasphryngl Hemrrg 1/2 W/Sec Surg Ivntj                     $494.65
42999         Unlis Px Pharynx Adenoids/Tonsils                                  $0.00
43000         Esophagotomy, Cervical Approach; Without Removal Of Foreign     $520.87
43020         Esophagotomy Crv Appr W/Rmvl Fb                                 $544.01
43030         Cricopharyngeal Myotomy                                         $528.58
43040         Esophagotomy, Thoracic Approach; Without Removal Of Foreign     $713.04
43045         Esophagotomy Thrc Appr W/Rmvl Fb                               $1,248.43
43100         Exc Les Esoph W/Prim Rpr Crv Appr                               $610.38
43101         Exc Les Esoph W/Prim Rpr Thrc/Abdl Appr                         $984.27
43105         Wide Excision Of Malignant Lesion Of Cervical Esophagus, Wit   $1,386.01
43106         Wide Excision Of Malignant Lesion Of Cervical Esophagus, Wit   $1,658.31
43107         Tot Esphg W/O Thorcom Phrngstrsty/Egst                         $2,278.71
43108         Tot Esphg W/O Thorcom Colon Ntrpstj/Int Rcnstj                 $1,982.46
43110         Esophagectomy (At Upper Two-Thirds Level) And Gastric Anasto   $2,137.55
43111         Esophagectomy (At Upper Two-Thirds Level) And Gastric Anasto   $1,762.95
43112         Tot Esphg W/Thorcom W/Phrngstrsty/Egst                         $2,467.91
43113         Tot Esphg W/Thorcom W/Colon Ntrpstj/Int Rcnstj                 $2,082.51
43115         Esophagectomy (At Upper Two-Thirds Level) With Segment Repla   $2,369.79
43116         Prtl Esphg Crv W/Fr Intstinal Grf                              $1,906.25
43117         Prtl Esphg Dstl Thorcom Abdl Inc Egst                          $2,261.54
43118         Prtl Esphg Dstl Thorcom Abdl Inc Ntrpstj/Rcnstj                $1,918.80
43119         Total Esophagectomy With Gastropharyngostomy, Without Thorac   $2,128.61
43120         Esophagogastrectomy (Lower Third) And Vagotomy, Combined Tho   $2,030.19
43121         Prtl Esphg Dstl Thorcom Only Thrc Egst                         $1,722.86
43122         Prtl Esphg Thoracoabdl/Abdl Appr Egst                          $2,253.75
43123         Prtl Esphg Thoracoabdl/Abdl Appr Ntrpstj/Rcnstj                $1,950.07
43124         Tot/Prtl Esphg W/O Rcnstj W/Crv Esophagostomy                  $1,644.00
43130         Diverticulectomy Hypopharynx/Esoph Crv Appr                     $768.31
43135         Diverticulectomy Hypopharynx/Esoph Thrc Appr                    $989.11
43136         Diverticulopexy Of Hypopharynx, With Or Without Myotomy         $891.16
43200         Esphgsc Rgd/Flx Dx +-Collj Spec Br/Wa Spx                       $211.09

                                          Page 67
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                          Amount
43201         Esphgsc Rgd/Flx Dired Sbmcsl Njx Any Sbst           $255.36
43202         Esphgsc Rgd/Flx W/Bx 1/Mlt                          $272.72
43204         Esphgsc Rgd/Flx W/Njx Sclerosis Esophgl Varc        $205.58
43205         Esphgsc Rgd/Flx W/Band Lig Esophgl Varc             $206.28
43215         Esphgsc Rgd/Flx W/Rmvl Fb                           $150.17
43216         Esphgsc Rgd/Flx Rmvl Tum Hot Bx Forceps/Caut        $140.02
43217         Esphgsc Rgd/Flx W/Rmvl Tum Snare Tq                 $364.77
43218         43200 W/Irrig                                       $423.50
43219         Esphgsc Rgd/Flx W/Insj Plstc Tube/Stent             $162.30
43220         Esphgsc Rgd/Flx W/Balo Dilat < 30 Mm Diam           $120.26
43225         43200 W/ Rpr Hypopharngeal Diverticulum             $399.30
43226         Esphgsc Rgd/Flx W/Insj Gd Wire Dilat                $131.77
43227         Esphgsc Rgd/Flx W/Ctrl Bld                          $196.67
43228         Esphgsc Rgd/Flx Abltj Tum Xcp Hot Bx/Caut/Snare     $210.29
43231         Esphgsc Rgd/Flx W/Ndsc Us Xm                        $177.44
43232         Esphgsc Rgd/Flx W/Tndsc Us-Gid Fine Ndl Aspir/Bx    $246.70
43234         Upper Stomach-Intestine Scope, Simple               $271.81
43235         Upper Stomach-Intestine Scope For Diagnosis         $279.79
43236         Stomach-Intestine Scope, Inject Intestine Wall      $346.72
43237         Upr Gi Ndsc Ndsc Us Xm Lmtd Esoph                   $218.38
43238         Upr Gi Ndsc Tndsc Us Fine Ndl Aspir/Bx Esoph        $270.36
43239         Upper Stomach-Intestine Scope For Biopsy            $317.84
43240         Upr Gi Ndsc Transmural Drg Pseudocst                $370.03
43241         Upr Gi Ndsc Tndsc Intral Tube/Cath Plmt             $145.25
43242         Stomach-Intestine Scope Ultrasound Guided Biopsy    $388.32
43243         Upr Gi Ndsc Njx Sclerosis Esophgl&/Gstr Varc        $247.62
43244         Upr Gi Ndsc Band Lig Esophgl&/Gstr Varc             $271.75
43245         Upr Gi Ndsc Dilat Gstr Outlet For Obstrcj           $176.62
43246         Upr Gi Ndsc Dired Plmt Prq Gastrostomy Tube         $236.64
43247         Stomach-Intestine Scope For Foreign Body Removal    $186.60
43248         Upr Gi Ndsc Insj Gd Wire Dilat Esoph > Gd Wire      $174.23
43249         Upr Gi Ndsc Balo Dilat Esoph < 30 Mm Diam           $161.25
43250         Upr Gi Ndsc Rmvl Les Hot Bx/Bipolar Caut            $177.32
43251         Upr Gi Ndsc Rmvl Tum Polyp/Oth Les Snare Tq         $203.00
43255         Upr Gi Ndsc Ctrl Bld Any Meth                       $259.47
43256         Upr Gi Ndsc Tndsc Stent Plmt W/Predilat             $238.07
43257         Upr Gi Ndsc Dlvr Thermal Nrg Sphnctr/Cardia         $305.14
43258         Upr Gi Ndsc Abltj Les X Rmvl Forceps/Caut/Snare     $247.69
43259         Stomach-Intestine Scope With Ultrasound Exam        $279.26
43260         Ercp Dx Collj Spec Br/Wa Spx                        $319.94
43261         Ercp W/Bx 1/Mlt                                     $336.35
43262         Ercp W/Sphnctrotomy/Papillotomy                     $394.85
43263         Ercp W/Press Meas Sphnctr Oddi                      $387.17
43264         Ercp W/Rmvl St1/Calculi Biliary&/Pncrtc Duxs        $474.20
43265         Ercp W/Dstrj Lithotrp St1/Calculi Any Meth          $530.33
43267         Ercp W/Insj Nasobiliary/Nasopncrtc Drg Tube         $394.48
43268         Ercp W/Insj Tube/Stent Bile/Pncrtc Dux              $398.13
43269         Ercp W/Rtrgr Rmvl Fb&/Chng Tube/Stent               $433.20
43271         Ercp W/Balo Dilat Ampulla Biliary&/Pncrtc Dux       $394.48
43272         Ercp W/Abltj Les X Rmvl Forceps/Caut/Snare          $394.85
43280         Laps Surg Esopg/Gstr Fundoplasty                    $996.89
43289         Unlis Laps Px Esoph                                    $0.00
43300         Esphgp Crv Appr W/O Rpr Tracheoesophgl Fstl         $620.53
43305         Esphgp Crv Appr W/Rpr Tracheoesophgl Fstl          $1,108.56
43310         Esphgp Thrc Appr W/O Rpr Tracheoesophgl Fstl       $1,509.94

                                           Page 68
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
43312         Esphgp Thrc Appr W/Rpr Tracheoesophgl Fstl                     $1,663.87
43313         Esphgp Cgen Dfct Thrc Appr W/O Rpr Fstl                        $2,690.39
43314         Esphgp Cgen Dfct Thrc Appr W/Rpr Fstl                          $2,950.60
43320         Egst+-Vagotomy&Pyloroplasty Tabdl/Tthrc Appr                   $1,159.66
43321         Esophagogastrostomy (Cardioplasty) With Or Without Vagotomy    $1,193.84
43324         Esopg/Gstr Fundoplasty                                         $1,173.23
43325         Esopg/Gstr Fundoplasty W/Fundic Patch                          $1,151.66
43326         Esopg/Gstr Fundoplasty W/Gastroplasty                          $1,167.33
43330         Esophagomyotomy Heller Typ Abdl Appr                           $1,125.19
43331         Esophagomyotomy Heller Typ Thrc Appr                           $1,204.26
43340         Esophagojejunostomy W/O Tot Gstrct Abdl Appr                   $1,136.10
43341         Esophagojejunostomy W/O Tot Gstrct Thrc Appr                   $1,249.72
43350         Esophagostomy Fstlj Esoph Xtrnl Abdl Appr                       $955.39
43351         Esophagostomy Fstlj Esoph Xtrnl Thrc Appr                      $1,117.77
43352         Esophagostomy Fstlj Esoph Xtrnl Crv Appr                        $940.26
43360         Gi Rcnstj Prev Esphg/Exclusion W/Stomach                       $2,031.62
43361         Gi Rcnstj Prev Esphg/Exclusion W/Colon Sm Int                  $2,302.93
43400         Lig Dir Esophgl Varc                                           $1,183.21
43401         Trnsxj Esoph W/Rpr Esophgl Varc                                $1,257.81
43405         Lig/Stapling G-Esop Junct Pre-Esophgl Prf8J                    $1,177.46
43410         Sutr Esophgl Wnd/Inj Crv Appr                                   $839.57
43415         Sutr Esophgl Wnd/Inj Tthrc/Tabdl Appr                          $1,457.25
43420         Clsr Esophagostomy/Fstl Crv Appr                                $850.51
43425         Clsr Esophagostomy/Fstl Tthrc/Tabdl Appr                       $1,250.05
43450         Opening Of Esophagus                                            $146.80
43451         Dilation Of Esophagus, By Unguided Sound Or Bougie, Single O      $71.28
43453         Dilat Esoph > Gd Wire                                           $277.72
43455         Dilation Of Esophagus, By Balloon Or Dilator; Under Fluorosc    $197.62
43456         Dilat Esoph Balo/Dilator Rtrgr                                  $604.97
43458         Dilat Esoph Balo 30 Mm Diam/Lgr Achalasia                       $361.98
43460         Esopg/Gstr Tamponade W/Balo Sengstaaken Typ                     $206.09
43496         Fr Jejunum Tr W/Mvasc Anast                                        $0.00
43499         Unlis Px Esoph                                                     $0.00
43500         Gstrt W/Expl/Fb Rmvl                                            $635.52
43501         Gstrt W/Sutr Rpr Bld Ulcer                                     $1,128.50
43502         Gstrt W/Sutr Rpr Pre-Esopg/Gstr Lac                            $1,299.70
43510         Gstrt W/Esophgl Dilat&Insj Prm Intral Tube                      $772.63
43520         Pyloromyotomy Cutting Pyloric Musc                              $607.27
43600         Bx Stomach Capsl Tube Proral 1+ Specs                           $114.22
43605         Bx Stomach Lapt                                                 $686.40
43610         Exc Local Ulcer/B9 Tum Stomach                                  $826.53
43611         Exc Local Mal Tum Stomach                                      $1,010.42
43620         Gstrct Tot W/Esophagontrstm                                    $1,665.52
43621         Gstrct Tot W/Roux-En-Y Rcnstj                                  $1,701.88
43622         Gstrct Tot W/Frmj Intstinal Pouch Any Typ                      $1,796.70
43625         Gastrectomy, Total; With Repair By Intestinal Transplant       $1,777.19
43630         Hemigastrectomy Or Distal Subtotal Gastrectomy Including Pyl   $1,196.44
43631         Gstrct Prtl Dstl W/Gastroduodenostomy                          $1,276.32
43632         Gstrct Prtl Dstl W/Gastrojejunostomy                           $1,276.73
43633         Gstrct Prtl Dstl W/Roux-En-Y Rcnstj                            $1,304.05
43634         Gstrct Prtl Dstl W/Frmj Intstinal Pouch                        $1,413.73
43635         Vagotomy Pfrmd W/Prtl Dstl Gstrct                                $112.65
43638         Gastrectomy, Partial, Proximal, Thoracic Or Abdominal Approa   $1,627.18
43639         Gastrectomy, Partial, Proximal, Thoracic Or Abdominal Approa   $1,647.80
43640         Vgtmy W/Pyps +-Gastrostomy Truncal/Slctv                        $975.00

                                            Page 69
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
43641         Vgtmy W/Pyps +-Gastrostomy Parietal Cell                        $989.57
43644         Laps Gstr Rstcv Px W/Byp Roux-En-Y <150 Cm                     $1,599.95
43645         Laps Gstr Rstcv Px W/Byp&Sm Int Rcnstj                         $1,725.93
43651         Laps Surg Trnsxj Vagus Nrv Truncal                              $603.97
43652         Laps Surg Trnsxj Vagus Nrv Slctv/Hily Slctv                     $711.54
43653         Laps Surg Gastrostomy W/O Constj Gstr Tube Spx                  $480.60
43659         Unlis Laps Px Stomach                                              $0.00
43750         Prq Plmt Gastrostomy Tube                                       $282.87
43752         Naso/Oro-Gastric Tube Plmt Req Phys&Fluor Gdn                     $35.70
43760         Surgical Change Of Stomach Tube                                 $104.58
43761         Rpsg Gstr Feeding Tube Any Meth Thru Duo                        $108.78
43770         Laps Gstr Rstcv Px Plmt Band                                   $1,012.19
43771         Laps Gstr Rstcv Px Revj Band                                   $1,165.59
43772         Laps Gstr Rstcv Px Rmvl Band                                    $888.35
43773         Laps Gstr Rstcv Px Rmvl&Rplcmt Band                            $1,166.00
43774         Laps Gstr Rstcv Px Rmvl Band&Port                               $890.38
43800         Pyloroplasty                                                    $779.81
43810         Gastroduodenostomy                                              $827.87
43820         Gastrojejunostomy W/O Vagotomy                                  $866.45
43825         Gastrojejunostomy W/Vagotomy Any Typ                           $1,084.49
43830         Gastrostomy Opn W/O Constj Gstr Tube Spx                         $567.43
43831         Gastrostomy Opn Neonatal Feeding                                $498.02
43832         Gastrostomy Opn W/Constj Gstr Tube                              $889.03
43840         Gastrorrhaphy Sutr Prf8 Duol/Gstr Ulcer Wnd/Inj                 $887.91
43842         Gstr Rstcv W/O Byp Ver-Banded Gstp                             $1,060.18
43843         Gstr Rstcv W/O Byp Oth/Thn Ver-Banded Gstp                     $1,067.02
43844         Gastric Bypass, Other Than With Roux-En-Y Gastroenterostomy,    $926.60
43845         Gstr Rstcv W/Prtl Gstrct 50-100 Cm                             $1,186.45
43846         Gstr Rstcv W/Byp W/Short Limb 150 Cm/<                         $1,371.19
43847         Gstr Rstcv W/Byp W/Sm Int Rcnstj Limit Absrpj                  $1,521.99
43848         Revj Opn Gstr Rstcv Oth/Thn Band Spx                           $1,660.38
43850         Revj Gastroduol Anast W/Rcnstj W/O Vagotomy                    $1,378.76
43855         Revj Gastroduol Anast W/Rcnstj W/Vgtmy                         $1,452.78
43860         Revj Gstr/Jj Anast W/Rcnstj W/O Vgtmy                          $1,397.91
43865         Revj Gstr/Jj Anast W/Rcnstj W/Vgtmy                            $1,479.71
43870         Clsr Gastrostomy Surg                                           $562.57
43880         Clsr Gastrocolic Fstl                                          $1,378.17
43885         Anterior Gastropexy For Hiatal Hernia (Separate Procedure)      $754.66
43886         Gstr Rstcv Px Opn Revj Subq Port Component Only                 $279.76
43887         Gstr Rstcv Px Opn Rmvl Subq Port Component Only                 $274.87
43888         Gstr Rstcv Opn Rmvl&Rplcmt Subq Port                            $389.89
43999         Unlis Px Stomach                                                   $0.00
44000         Enterolysis, Freeing Of Intestinal Adhesion;                    $786.50
44005         Enterolss Fring Intstinal Adhesion Spx                          $920.82
44010         Duodexomy Expl Bx/Fb Rmvl                                       $719.24
44015         Tube/Ndl Cath Jejunostomy Any Meth                              $142.53
44020         Enterotomy Sm Int Oth/Thn Duo Expl Bx/Fb Rmvl                   $798.98
44021         Enterotomy Sm Int Oth/Thn Duo Dcmprn                            $802.58
44025         Colotomy Expl Bx/Fb Rmvl                                        $813.50
44040         Exteriorization Of Intestine (Mikulicz Resection With Crushi    $943.33
44050         Rdctj Volvulus Intussusception Int Hrna Lapt                    $798.76
44055         Corrj Malrotation Bands&/Rdctj Volvulus                        $1,205.62
44060         Sigmoid Myotomy (Reilly Type Operation) For Diverticular           $0.00
44100         Bx Int Capsl Tube Proral 1+ Specs                               $120.91
44110         Exc 1+ < Sm/Lg Int 1 Enterotomy                                  $681.89

                                            Page 70
                         MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
44111         Exc 1+ < Sm/Lg Int Mlt Enterotomies                             $817.93
44115         Excision Colonic Diverticulum                                      $0.00
44120         Entrc Rescj Sm Int 1 Rescj&Anast                                $965.24
44121         Entrc Rescj Sm Int Ea Rescj&Anast                               $244.03
44125         Entrc Rescj Sm Int W/Ntrstm                                     $993.97
44126         Entrc Rescj Atresia Rescj&Anast W/O Tapring                    $1,858.18
44127         Entrc Rescj Atresia Rescj&Anast Sgm W/Tapring                  $2,125.12
44128         Entrc Rescj Atresia Ea Rescj&Anast                              $243.99
44130         Enterontrstm Anast Int +-Cutan Ntrstm Spx                       $829.09
44131         Enteroenterostomy, Anastomosis Of Intestine; Intestinal Bypa   $1,815.00
44132         Don Entrc Opn From Cdvr Don                                        $0.00
44133         Don Entrc Opn Prtl From Liv Don                                    $0.00
44135         Intstinal Altrnsplj From Cdvr Don                                  $0.00
44136         Intstinal Altrnsplj From Liv Don                                   $0.00
44139         Moblj Splenic Flxr Pfrmd Conjunct W/Prtl Colct                  $121.19
44140         Colct Prtl W/Anast                                             $1,205.29
44141         Colct Prtl W/Skn Lvl Cecostomy/Clst                            $1,193.61
44143         Colct Prtl W/End Clst&Clsr Dstl Sgm                            $1,350.94
44144         Colct Prtl W/Rescj W/Clst/Ileost&Mucofstl                      $1,249.38
44145         Colct Prtl W/Colopxtstmy Lw Pel Anast                          $1,490.96
44146         Colct Prtl W/Colopxtstmy Lw Pel Anast W/Clst                   $1,608.60
44147         Colct Prtl Abdl&Transanal Appr                                 $1,176.75
44150         Colct Tot Abdl W/O Prctect W/Ileost/Ileopxts                   $1,437.29
44151         Colct Tot Abdl W/O Prctect W/Continent Ileost                  $1,593.42
44152         Colectomy, Total, Abdominal, Without Proctectomy; With Recta   $1,580.10
44153         Colectomy, Total, Abdominal, Without Proctectomy; With Recta   $1,786.32
44155         Colct Tot Abdl W/Prctect W/Ileost                              $1,640.61
44156         Colct Tot Abdl W/Prctect W/Continent Ileost                    $1,810.24
44160         Colct Prtl W/Rmvl Terminal Ile W/Ileoclst                      $1,070.09
44180         Laps Enterolss Fring Intstinal Adhesion Spx                     $856.39
44186         Laps Jejunostomy                                                $602.16
44187         Laps Ileost/Jejunostomy Non-Tube                                $994.36
44188         Laps Clst/Skn Lvl Cecostomy                                    $1,091.18
44200         Laparoscopy, Surgical; Enterolysis (Freeing Of Intestinal Ad    $837.53
44201         Laparoscopy, Surgical; Jejunostomy (Eg, For Decompression Or    $584.03
44202         Laps Entrc Rescj Sm Int 1 Rescj&Anast                          $1,255.93
44203         Laps Ea Sm Int Rescj&Anast                                      $242.94
44204         Laps Colct Prtl W/Anast                                        $1,425.44
44205         Laps Colct Prtl W/Rmvl Terminal Ile                            $1,262.63
44206         Laps Colct Prtl W/End Clst&Clsr Dstl Sgm                       $1,521.11
44207         Laps Colct Prtl W/Colopxtstmy Lw Anast                         $1,650.92
44208         Laps Colct Prtl W/Colopxtstmy Lw Anast W/Clst                  $1,785.35
44209         Laparoscope Proc, Intestine                                        $0.00
44210         Laps Colct Tot W/O Prctect W/Ileost/Ileopxts                   $1,583.76
44211         Laps Colct Ttl Abd W/Prctect Ileoanal Anast&Rsvr               $1,957.55
44212         Laps Colct Abdl W/Prctect W/Ileost                             $1,829.55
44213         Laps Moblj Splenic Flxr Pfrmd W/Prtl Colct                      $196.33
44227         Laps Clsr Ntrstm Lg/Sm Int W/Rescj&Anast                       $1,541.19
44238         Unlis Laps Px Int Xcp Rectum                                       $0.00
44239         Unlisted Laparoscopy Procedure, Rectum                             $0.00
44300         Ntrstm/Cecostomy Tube Spx                                       $696.48
44305         Enterostomy Or Cecostomy, Tube (Eg, For Decompression Or Fee    $157.30
44308         Enterostomy, Suture Of One Wall Of Intestine To Abdominal      $1,137.40
44310         Ileost/Jejunostomy Non-Tube                                     $895.89
44312         Revj Ileost Smpl Rls Supfc Scar Spx                             $472.69

                                           Page 71
                           MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
44314         Revj Ileost Comp Rcnstj In-Depth Spx                            $850.62
44316         Continent Ileost Kock Px Spx                                   $1,169.55
44320         Clst/Skn Lvl Cecostomy                                         $1,001.72
44322         Clst/Skn Lvl Cecostomy W/Mlt Bxs Spx                            $822.04
44340         Revj Clst Smpl Rls Supfc Scar Spx                               $472.93
44345         Revj Clst Comp Rcnstj In-Depth Spx                              $882.96
44346         Revj Clst W/Rpr Paraclst Hrna Spx                               $963.57
44360         Scope Of Upper Small Intestine                                  $144.52
44361         Scope Of Upper Small Intestine With Biopsy                      $158.67
44363         Enteroscopy > 2Nd Prtn X Ile Rmvl Fb                            $190.79
44364         Enteroscopy > 2Nd Prtn X Ile Rmvl Les Snare                     $204.95
44365         Enteroscopy > 2Nd Prtn X Ile Rmvl Les Caut                      $182.93
44366         Enteroscopy > 2Nd Prtn X Ile Ctrl Bld                           $239.54
44369         Enteroscopy > 2Nd Prtn X Ile Abltj Les                          $244.06
44370         Enteroscopy > 2Nd Prtn X Ile Tndsc Stent Plmt                   $261.69
44372         Enteroscopy > 2Nd Prtn X Ile W/Plmt Prq Tube                    $241.62
44373         Enteroscopy > 2Nd Prtn X Ile Conv Gstrst Tube                   $192.62
44376         Enteroscopy > 2Nd Prtn W/Ile +-Collj Spec Spx                   $284.76
44377         Enteroscopy > 2Nd Prtn W/Ile W/Bx 1/Mlt                         $298.45
44378         Enteroscopy > 2Nd Prtn Ile Ctrl Bld                             $383.11
44379         Enteroscopy > 2Nd Prtn W/Ile W/Stent Plmt                       $404.25
44380         Ilesc Thru Stoma Dx +-Collj Spec Br/Wa Spx                        $63.72
44382         Ilesc Thru Stoma W/Bx 1/Mlt                                       $75.63
44383         Ilesc Thru Stoma W/Tndsc Stent Plmt                             $163.02
44385         Ndsc Eval Intstinal Pouch Dx +-Collj Spec Spx                   $255.50
44386         Ndsc Eval Intstinal Pouch W/Bx 1/Mlt                            $324.20
44388         Scope Of Colon Thru Ostomy For Diagnosis                        $301.94
44389         Scope Of Colon With Biopsy Thru Ostomy                          $362.81
44390         Colsc Thru Stoma W/Rmvl Fb                                      $400.47
44391         Colsc Thru Stoma Ctrl Bld                                       $486.72
44392         Colsc Thru Stoma Rmvl Les Caut                                  $392.10
44393         Colsc Thru Stoma Abltj Les                                      $445.73
44394         Colsc Thru Stoma W/Rmvl Tum Polyp/Oth Les Snare                 $460.65
44397         Colsc Thru Stoma W/Tndsc Stent Plmt                             $264.55
44400         Cecopexy, Fixation Of Cecum To Abdominal Wall                   $181.50
44405         Sigmoidopexy, Fixation Of Sigmoid Colon To Abdominal Wall          $0.00
44500         Intro Long Gi Tube Spx                                            $32.26
44600         Suture Of Intestine (Enterorrhaphy), Large Or Small, For Per    $706.14
44602         Enterorrhaphy 1 Prf8J                                           $884.70
44603         Enterorrhaphy Mlt Prf8J                                        $1,030.90
44604         Sutr Lg Int 1/Mlt Prf8J W/O Clst                                $904.35
44605         Sutr Lg Int 1/Mlt Prf8J W/Clst                                 $1,112.70
44610         Suture Of Intestine (Enterorrhaphy), Large Or Small, For Per    $892.12
44615         Intstinal Stricturoplasty+-Dilat Obstrcj                        $907.80
44620         Clsr Ntrstm Lg/Sm Int                                           $702.18
44625         Clsr Ntrstm Lg/Sm Rescj&Anast Oth/Thn Clrct                     $856.95
44626         Clsr Ntrstm Lg/Sm Rescj&Clrct Anast                            $1,429.92
44640         Clsr Intstinal Cutan Fstl                                      $1,193.63
44650         Clsr Enteroenteric/Enterocolic Fstl                            $1,240.93
44660         Clsr Enteroves Fstl W/O Intstinal/Bldr Rescj                   $1,158.90
44661         Clsr Enteroves Fstl W/Int&/Bldr Rescj                          $1,350.69
44680         Intstinal Plctj Spx                                             $878.02
44700         Exclusion Sm Int From Pelvis Mesh/Prosth/Tiss                   $904.47
44701         Intraop Colonic Lvg                                             $164.63
44720         Bkbench Rcnstj Int Algrft Ven Anast Ea                          $268.31

                                              Page 72
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
44721         Bkbench Rcnstj Int Algrft Artl Anast Ea                         $393.80
44799         Unlis Px Int                                                       $0.00
44800         Exc Meckel's Diverticulum/Omphalomesenteric Duct                $671.37
44820         Exc Les Mesentery Spx                                           $703.06
44850         Sutr Mesentery Spx                                              $632.73
44899         Unlis Px Meckel's Diverticulum And The Mesentery                   $0.00
44900         I&D Appendiceal Absc Opn                                        $592.04
44901         I&D Appendiceal Absc Prq                                        $175.27
44950         Appendec                                                        $574.98
44955         Appendec Indicated Purpose Oth Major Px X Spx                     $84.21
44960         Appendec Rptd Appendix Absc/Pritonitis                          $709.77
44970         Laps Surg Appendec                                              $522.06
44979         Unlis Laps Px Appendix                                             $0.00
45000         Transrct Drg Pel Absc                                           $295.52
45005         I&D Sbmcsl Absc Rectum                                          $259.99
45020         I&D Dp Supralevator Pelvirct/Retrorct Absc                      $316.67
45100         Bx Anrct Wall Anal Appr                                         $240.58
45108         Anrct Myomectomy                                                $306.00
45110         Prctect Compl Cmbn Abdominoprnl W/Clst                         $1,611.51
45111         Prctect Prtl Rescj Rectum Tabdl Appr                            $956.40
45112         Prctect Cmbn Abdominoprnl Pull-Thru Px                         $1,685.21
45113         Prctect Prtl W/Mucosec Ileoanal Anast Rsvr                     $1,707.89
45114         Prctect Prtl W/Anast Abdl&Transsac Appr                        $1,532.52
45116         Prctect Prtl W/Anast Transsac Appr Only                        $1,382.42
45119         Prctect Cmbn Pull-Thru W/Rsvr W/Ntrstm                         $1,712.12
45120         Prctect Compl W/Pull-Thru Px&Anast                             $1,401.02
45121         Prctect Compl W/Stot/Tot Colct W/Mlt Bxs                       $1,547.00
45123         Prctect Prtl W/O Anast Prnl Appr                                $925.62
45126         Pel Exntj Clrct Mal                                            $2,549.94
45130         Exc Rct Procidentia W/Anast Prnl Appr                           $916.33
45135         Exc Rct Procidentia W/Anast Abdl&Prnl Appr                     $1,102.88
45136         Exc Ileoanal Rsvr W/Ileost                                     $1,608.49
45150         Div Strix Rectum                                                $342.53
45160         Exc Rct Tum Proctotomy Transsac/Transcoccygeal                  $867.69
45170         Exc Rct Tum Transanal Appr                                      $664.25
45180         Excision And/Or Electrodesiccation Of Malignant Tumor Of Rec    $546.16
45190         Dstrj Rct Tum Transanal Appr                                    $571.63
45300         Proctosgmdsc Rgd Dx +-Collj Spec Br/Wa Spx                        $70.31
45302         Proctosigmoidoscopy; With Collection Of Specimen By Brushing      $61.40
45303         Proctosgmdsc Rgd W/Dilat                                          $88.80
45305         Proctosgmdsc Rgd W/Bx 1/Mlt                                     $136.40
45307         Proctosgmdsc Rgd W/Rmvl Fb                                      $151.97
45308         Proctosgmdsc Rgd Rmvl 1 Les Caut                                $108.34
45309         Proctosgmdsc Rgd Rmvl 1 Les Snare Tq                            $184.74
45310         Proctosigmoidoscopy; With Removal Of Polyp Or Papilloma         $120.69
45315         Proctosgmdsc Rgd Rmvl Mlt Tum < Caut/Snare                      $164.28
45317         Proctosgmdsc Rgd Ctrl Bld                                       $152.68
45319         Proctosigmoidscpy;W/Retrogrd Lavage                               $18.15
45320         Proctosgmdsc Rgd Abltj Les                                      $172.47
45321         Proctosgmdsc Rgd Dcmprn Volvulus                                  $73.41
45327         Proctosgmdsc Rgd Tndsc Stent Plmt                                 $92.05
45330         Scope Of Sigmoid Colon Only For Diagnosis                       $118.62
45331         Scope Of Sigmoid Colon Only With Biopsy                         $152.46
45332         Sgmdsc Flx Rmvl Fb                                              $249.59
45333         Sgmdsc Flx Rmvl Les Caut                                        $244.89

                                            Page 73
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
45334         Sgmdsc Flx Ctrl Bld                                             $152.75
45335         Sgmdsc Flx Dired Sbmcsl Njx Any Sbst                            $183.38
45336         Sigmoidoscopy, Flexible Fiberoptic; With Ablation Of Tumor O    $248.29
45337         Sgmdsc Flx Dcmprn Volvulus Any Meth                             $133.78
45338         Sgmdsc Flx Rmvl Tum Polyp/Oth Les Snare Tq                      $278.37
45339         Sgmdsc Flx Abltj Les                                            $247.75
45340         Sgmdsc Flx Dilat Balo 1/More Strixs                             $319.21
45341         Sgmdsc Flx Ndsc Us Xm                                           $147.74
45342         Sgmdsc Flx Tndsc Us Gid Ndl Aspir/Bx                            $221.04
45345         Sgmdsc Flx Tndsc Stent Plmt                                     $160.17
45355         Colsc Rgd/Flx Tabdl Via Colotomy 1/Mlt                          $194.79
45360         Colonoscopy, Fiberoptic, Beyond 25 Cm To Splenic Flexure;       $350.90
45365         Colonoscopy, Fiberoptic, Beyond 25 Cm To Splenic Flexure;       $375.10
45367         Colonoscopy, Fiberoptic, Beyond 25 Cm To Splenic Flexure;       $399.30
45368         Colonoscopy, Fiberoptic, Beyond 25 Cm To Splenic Flexure;       $363.00
45369         Colonoscopy, Fiberoptic, Beyond 25 Cm To Splenic Flexure;       $205.70
45370         Colonoscopy, Fiberoptic, Beyond 25 Cm To Splenic Flexure;       $859.10
45371         Colnscpy Fibrptc Beynd 25Cm Splnc;W/Lavage                        $18.15
45372         Colonoscopy, Fiberoptic, Beyond 25 Cm To Splenic Flexure;       $339.80
45378         Scope Of Colon For Diagnosis                                    $368.10
45379         Colsc Flx Prox Splenic Flxr Rmvl Fb                             $463.01
45380         Scope Of Colon With Biopsy                                      $433.75
45381         Colsc Flx Prox Splenic Flxr Sbmcsl Njx                          $463.86
45382         Colsc Flx Prox Splenic Flxr Ctrl Bld                            $580.44
45383         Colsc Flx Prox Splenic Flxr Abltj Les                           $521.32
45384         Colsc Flx Prox Splenic Flxr Rmvl Les Caut                       $431.21
45385         Colsc Flx Prox Splenic Flxr Rmvl Les Snare Tq                   $492.53
45386         Colsc Flx Prox Splenic Flxr Dilat Balo 1+ Strixs                $679.25
45387         Colsc Flx Prox Splenic Flxr Tndsc Stent Plmt                    $322.38
45391         Colsc Flx Prox Splenic Flxr Ndsc Us Xm                          $283.45
45392         Colsc Flx Prox Splenic Flxr Us Gid Ndl Aspir/Bx                 $357.44
45395         Laps Prctect Compl Cmbn Abdominoprnl W/Clst                    $1,817.95
45397         Laps Prctect Cmbn Pull-Thru Crtj Rsvr                          $1,974.39
45400         Laps Proctopexy For Prolapse                                   $1,061.38
45402         Laps Proctopexy For Prolapse Sigmoid Rescj                     $1,439.11
45500         Proctoplasty Stenosis                                           $430.58
45505         Proctoplasty Prolapse Muc Memb                                  $448.38
45520         Prirct Njx Sclrsg Sln Prolapse                                    $53.61
45521         Perirectal Injection Of Sclerosing Solution For Prolapse          $30.25
45540         Proctopexy Abdl Appr                                            $914.62
45541         Proctopexy Prnl Appr                                            $761.81
45550         Proctopexy W/Sigmoid Rescj Abdl Appr                           $1,274.61
45560         Rpr Rectocele Spx                                               $617.06
45562         Expl Rpr&Presac Drg Rct Inj                                     $887.51
45563         Expl Rpr&Presac Drg Rct Inj W/Clst                             $1,352.60
45800         Clsr Rectovesical Fstl                                          $991.99
45805         Clsr Rectovesical Fstl W/Clst                                  $1,197.34
45820         Clsr Rectourtl Fstl                                            $1,027.43
45825         Clsr Rectourtl Fstl W/Clst                                     $1,201.79
45900         Rdctj Procidentia Spx Under Anes                                $161.50
45905         Dilat Anal Sphnctr Spx Under Anes Oth/Thn Local                 $145.01
45910         Dilat Rct Strix Spx Under Anes Oth/Thn Local                    $172.08
45915         Rmvl Fecal Impaction/Fb Spx Under Anes                          $298.51
45990         Anrct Xm Surg Req Anes General Spi/Edrl Dx                      $104.80
45999         Unlis Px Rectum                                                    $0.00

                                             Page 74
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                     Amount
46000         Fistulotomy, Subcutaneous                                      $141.51
46020         Plmt Seton                                                     $202.52
46030         Rmvl Anal Seton Oth Marker                                     $100.51
46032         Undercutting For Pruritus Ani (Modified Ball Operation)          $48.40
46040         I&D Ischiorct&/Prirct Absc Spx                                 $401.96
46045         I&D Intramural Im/Absc Transanal Anes                          $287.09
46050         I&D Prianal Absc Supfc                                         $143.57
46060         I&D Ischiorct/Intramural Absc +-Seton                          $358.22
46070         Inc Anal Septum Inft                                           $183.26
46080         Sphnctrotomy Anal Div Sphnctr Spx                              $191.64
46083         Inc Thrombosed Hemorrhoid Xtrnl                                $149.26
46200         Fissurectomy +-Sphnctrotomy                                    $274.89
46210         Cryptectomy 1                                                  $287.95
46211         Cryptectomy Mlt Spx                                            $362.13
46220         Papillectomy/Exc 1 Tag Anus Spx                                $148.06
46221         Hemorrhoidectomy Smpl Ligature                                 $141.02
46230         Exc Xtrnl Hemorrhoid Tags&/Mlt Papillae                        $217.95
46250         Hrhc Xtrnl Compl                                               $343.50
46255         Hrhc Smpl                                                      $393.80
46257         Hrhc Smpl W/Fissurectomy                                       $336.41
46258         Hrhc Smpl W/Fistulectomy                                       $365.78
46260         Hrhc Cplx/X10Sv                                                $389.88
46261         Hrhc Cplx/X10Sv W/Fissurectomy                                 $431.81
46262         Hrhc Cplx/X10Sv W/Fistulectomy +-Fissurectomy                  $455.49
46270         Surg Tx Anal Fstl Subq                                         $326.19
46275         Surg Tx Anal Fstl Submuscular                                  $348.63
46280         Surg Tx Anal Fstl Cplx/Mlt +-Plmt Seton                        $368.19
46281         Closure Of Anal Fistula With Rectal Advancement Flap           $441.90
46285         Surg Tx Anal Fstl 2Nd Stg                                      $300.12
46288         Clsr Anal Fstl W/Rct Advmnt Flap                               $430.98
46320         Encl/Exc Xtrnl Thrombotic Hemorrhoid                           $144.45
46500         Njx Sclrsg Sln Hemorrhoids                                     $167.69
46505         Chemodnrvtj Int Anal Sphnctr                                   $228.72
46510         Perianal Injection Of Alcohol Or Other Solution For              $36.30
46530         Dilation Of Anus And Lower Rectum Under Anesthesia               $90.75
46600         Anosc Dx +-Collj Spec Br/Wa Spx                                  $78.40
46602         Anoscopy; For Collection Of Specimen By Brushing Or Washing      $39.52
46604         Anosc Dilat                                                    $392.99
46606         Anosc Bx 1/Mlt                                                 $173.36
46608         Anosc Rmvl Fb                                                  $224.29
46610         Anosc Rmvl 1 Les Caut                                          $203.97
46611         Anosc Rmvl 1 Tum Polyp/Oth Les Snare Tq                        $197.23
46612         Anosc Rmvl Mlt Tums Caut/Snare                                 $285.84
46614         Anosc Ctrl Bld                                                 $165.22
46615         Anosc Abltj Les                                                $203.48
46700         Anoplasty Plstc Opration Strix Adlt                            $523.02
46705         Anoplasty Plstc Opration Strix Inft                            $430.00
46706         Rpr Anal Fstl W/Fibrin Glue                                    $143.06
46710         Rpr Ileoanal Pouch Fstl/Pouch Advmnt Tprnl Appr                $954.38
46712         Rpr Ileoanal Pouch Fstl/Pouch Advmnt Cmbn Appr                $2,003.71
46715         Rpr Lw Imprf8 Anus W/Anoprnl Fstl Cut-Bk                       $438.82
46716         Rpr Lw Imprf8 Anus W/Trpos Fstl                                $917.22
46730         Rpr Hi Imprf8 Anus W/O Fstl Prnl/Sacroprnl Appr               $1,536.64
46735         Rpr Hi Imprf8 Anus W/O Fstl Cmbn Appr                         $1,824.58
46740         Rpr Hi Imprf8 Anus W/Fstl Prnl/Sacroprnl Appr                 $1,698.68

                                            Page 75
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                     Amount
46742         Rpr Hi Imprf8 Anus W/Fstl Tabdl&Sacroprnl                     $2,104.31
46744         Rpr Cloacal Anomal Sacroprnl                                  $2,846.64
46746         Rpr Cloacal Anomal Cmbn Abdl&Sacroprnl                        $3,213.94
46748         Rpr Cloacal Anomal Cmbn Abdl&Sacroprnl W/Grf                  $3,399.08
46750         Sphnctrop Anal Incont/Prolapse Adlt                            $601.97
46751         Sphnctrop Anal Incont/Prolapse Chld                            $566.53
46753         Grf Thiersch Rct Incont&/Prolapse                              $479.32
46754         Rmvl Thiersch Wire/Sutr Anal Canal                             $218.93
46760         Sphnctrop Anal Musc Trnspl                                     $839.99
46761         Sphnctrop Anal Levator Musc Imbrcj                             $778.39
46762         Sphnctrop Anal Impltj Artif Sphnctr                            $711.84
46900         Dstrj Les Anus Smpl Chem                                       $207.09
46910         Dstrj Les Anus Smpl Eltrdsiccation                             $174.23
46916         Dstrj Les Anus Smpl Cryosurg                                   $187.85
46917         Dstrj Les Anus Smpl Laser Surg                                 $412.03
46922         Dstrj Les Anus Smpl Surg Exc                                   $199.23
46924         Dstrj Les Anus X10Sv                                           $430.14
46934         Dstrj Hemorrhoids Any Meth Int                                 $326.24
46935         Dstrj Hemorrhoids Any Meth Xtrnl                               $225.26
46936         Dstrj Hemorrhoids Any Meth Int&Xtrnl                           $314.55
46937         Cryosurg Rct Tum B9                                            $205.82
46938         Cryosurg Rct Tum Mal                                           $347.25
46940         Curtg/Caut Anal Fissure W/Dilat Sphnctr Spx 1St                $167.84
46942         Curtg/Caut Anal Fissure W/Dilat Sphnctr Spx Sbsq               $150.28
46945         Lig Int Hemorrhoids 1 Px                                       $206.51
46946         Lig Int Hemorrhoids Mlt Px                                     $259.59
46947         Hemorrhoidopexy Stapling                                       $328.61
46999         Unlis Px Anus                                                     $0.00
47000         Bx Lvr Ndl Prq                                                  $194.46
47001         Bx Lvr Ndl Done Purpose Tm Oth Major Px                        $103.63
47010         Hepatotomy Opn Drg Absc/Cst 1/2 Stgs                           $940.98
47011         Hepatotomy Prq Drg Absc/Cst 1/2 Stgs                           $190.51
47015         Lapt W/Aspir&/Njx Hepatc Parasitic Cst/Absces                  $881.81
47100         Bx Lvr Wedge                                                    $694.36
47120         Hptc Rescj Lvr Prtl Lobec                                     $1,993.90
47122         Hptc Rescj Lvr Trisgmectomy                                   $3,021.53
47125         Hptc Rescj Lvr Tot L Lobec                                    $2,708.56
47130         Hptc Rescj Lvr Tot R Lobec                                    $2,931.43
47133         Don Hptc From Cdvr Don                                            $0.00
47135         Lvr Altrnsplj Orthotopic Prtl/Whl Don Any Age                 $4,609.58
47136         Lvr Altrnsplj Htrtpc Prtl/Whl Don Any Age                     $3,902.03
47140         Don Hptc Liv Don L Lat Sgm Only Ii&Iii                        $3,076.29
47141         Don Hptc Liv Don Tot L Lobec Ii Iii&Iv                        $3,712.06
47142         Don Hptc Liv Don Tot R Lobec V Vi Vii&Viii                    $4,085.93
47146         Bkbench Rcnstj Lvr Grf Ven Anast Ea                            $337.53
47147         Bkbench Rcnstj Lvr Grf Artl Anast Ea                            $393.80
47300         Marsupialization Cst/Absc Lvr                                  $876.12
47350         Mgmt Lvr Hemrrg Smpl Sutr Lvr Wnd/Inj                         $1,116.74
47355         Hepatorrhaphy, Suture Of Liver Wound Or Injury; With Common    $876.03
47360         Mgmt Lvr Hemrrg Cplx Sutr Wnd/Inj                             $1,513.61
47361         Mgmt Lvr Hemrrg Expl Wnd Dbrdmt Coagj/Sutr                    $2,590.00
47362         Mgmt Lvr Hemrrg Re-Expl Wnd Rmvl Packing                      $1,071.16
47370         Laps Surg Abltj 1+ Lvr Tum Rf                                 $1,074.67
47371         Laps Surg Abltj 1+ Lvr Tum Cryosurg                           $1,075.04
47379         Unlis Laparoscopic Px Lvr                                         $0.00

                                            Page 76
                         MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                  Amount
47380         Abltj Opn 1+ Lvr Tum Rf                                    $1,242.44
47381         Abltj Opn 1+ Lvr Tum Cryosurg                              $1,262.02
47382         Abltj 1+ Lvr Tum Prq Rf                                      $844.91
47399         Unlis Px Lvr                                                   $0.00
47400         Hepatcotomy/Hepatcostomy W/Expl Drg/Rmvl St1               $1,795.55
47420         Choledochot/Ost W/O Sphnctrotomy/Sphnctrop                 $1,146.65
47425         Choledochot/Ost W/Sphnctrotomy/Sphnctrop                   $1,141.72
47440         Duodenocholedochotomy, Transduodenal Choledocholithotomy   $1,219.52
47460         Transduol Sphnctrotomy/Sphnctrop +-Xtrj St1 Spx            $1,040.96
47480         Cholecstot/Cholecstost W/Expl Drg/Rmvl St1 Spx               $663.16
47490         Prq Cholecstost                                              $498.74
47500         Njx Prq Transhepatc Cholangrph                               $101.03
47505         Njx Cholangrph Thru An Cath                                  $124.95
47510         Intro Prq Transhepatc Cath Biliary Drg                       $492.42
47511         Intro Prq Transhepatc Stent Biliary Drg                      $600.36
47525         Chng Prq Biliary Drg Cath                                    $337.69
47530         Revj&/Rinsj Transhepatc Tube                                 $390.04
47550         Biliary Ndsc Intraop                                         $165.02
47552         Biliary Ndsc Prq T-Tube Dx +-Collj Spec Spx                  $333.54
47553         Biliary Ndsc Prq T-Tube W/Bx 1/Mlt                           $346.31
47554         Biliary Ndsc Prq T-Tube Rmvl St1                             $497.55
47555         Biliary Ndsc Prq T-Tube Dilat Strix W/O Stent                $408.90
47556         Biliary Ndsc Prq T-Tube Dilat Strix W/Stent                  $459.55
47560         Laps Surg W/Gid Transhepatc Cholangrph W/O Bx                $273.04
47561         Laps Surg W/Gid Transhepatc Cholangrph W/Bx                  $294.83
47562         Laps Surg Cholecstc                                          $651.25
47563         Laps Surg Cholecstc W/Cholangrph                             $698.75
47564         Laps Surg Cholecstc W/Expl Common Dux                        $819.38
47570         Laps Surg Cholecstontrstm                                    $728.45
47579         Unlis Laps Px Biliary Trc                                      $0.00
47600         Cholecstc                                                    $789.67
47605         Cholecstc Cholangrph                                         $848.37
47610         Cholecstc Expl Dux                                         $1,072.29
47611         47610 W/Biliary Endoscopy                                  $1,488.30
47612         Cholecstc Expl Dux Choledochontrstm                        $1,068.56
47620         Cholecstc Expl Dux Sphnctrotomy/Sphnctrop                  $1,169.88
47630         Biliary Dux Stone Xtrj Prq Via Basket/Snare                  $537.43
47700         Expl Cgen Atresia Bile Duxs                                  $924.38
47701         Portontrstm                                                $1,607.04
47710         Excision Of Bile Duct Tumor, With Repair                   $1,296.15
47711         Exc Bile Dux Tum +-Prim Rpr Xtrhepatc                      $1,321.55
47712         Exc Bile Dux Tum +-Prim Rpr Intrahepatc                    $1,714.71
47715         Exc Choledochal Cst                                        $1,088.98
47716         Anastomosis, Choledochal Cyst, Without Excision              $970.01
47720         Cholecstontrstm Dir                                          $935.77
47721         Cholecstontrstm W/Gastrontrstm                             $1,108.08
47740         Cholecstontrstm Roux-En-Y                                  $1,075.57
47741         Cholecstontrstm Roux-En-Y W/Gastrontrstm                   $1,226.62
47760         Anast Xtrhepatc Biliary Duxs&Gi                            $1,471.10
47765         Anast Intrahepatc Duxs&Gi                                  $1,432.16
47780         Anast Roux-En-Y Xtrhepatc Biliary Duxs&Gi                  $1,511.36
47785         Anast Roux-En-Y Intrahepatc Biliary Duxs&Gi                $1,769.25
47800         Rcnstj Plstc Biliary Duxs W/End-To-End Anast               $1,334.39
47801         Plmt Choledochal Stent                                       $903.62
47802         U-Tube Hepatcontrstm                                       $1,250.25

                                          Page 77
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
47810         Implantation Of Biliary Fistulous Tract Into Stomach Or        $2,420.00
47850         Choledochorrhaphy                                              $1,089.00
47855         Cholecystorrhaphy                                              $1,089.00
47900         Sutr Xtrhepatc Biliary Dux F/Pre-Inj Spx                       $1,148.97
47999         Unlis Px Biliary Trc                                               $0.00
48000         Plmt Drains Pripncrtc F/Aqt Pncrts                             $1,534.13
48001         Plmt Drains Pripncrtc F/Aqt Pncrts W/Cholecstost               $1,924.34
48005         Resection Or Debridement Of Pancreas And Peripancreatic Tiss   $2,290.64
48020         Rmvl Pncrtc St1                                                  $920.59
48100         Bx Pncrs Opn                                                     $715.11
48102         Bx Pncrs Prq Ndl                                                $514.24
48120         Exc Les Pncrs                                                    $909.35
48140         Pncrtect Dstl Stot W/O Pncrtcojejunostomy                      $1,310.14
48145         Pncrtect Dstl Stot W/Pncrtcojejunostomy                        $1,367.52
48146         Pncrtect Dstl Nr-Tot W/Prsrv Duo Chld-Typ Px                   $1,544.94
48148         Exc Ampulla Vater                                              $1,005.71
48150         Pncrtect Prox Stot W/Pancreatojejunostomy                      $2,724.45
48151         Pancreatectomy, Near-Total, With Preservation Of Duodenum (C   $1,492.65
48152         Pncrtect Whipple W/O Pancreatojejunostomy                      $2,500.79
48153         Pncrtect W/Pancreatojejunostomy                                $2,722.40
48154         Pncrtect Prox Stot W/O Pancreatojejunostomy                    $2,516.58
48155         Pncrtect Tot                                                   $1,462.85
48160         Pncrtect Tot/Stot W/Trnsplj Pncrs/Islet                            $0.00
48180         Pancreaticojejunostomy, Side-To-Side Anastomosis (Puestow-Ty   $1,404.56
48400         Njx Px F/Intraop Pancreatograpy                                 $101.06
48500         Marsupialization Pncrtc Cst                                     $906.32
48510         Xtrnl Drg Pseudocst Pncrs Opn                                   $861.38
48511         Xtrnl Drg Pseudocst Pncrs Prq                                   $205.36
48520         Int Anast Pncrtc Cst Gi Trc Dir                                  $897.01
48540         Int Anast Pncrtc Cst Gi Trc Roux-En-Y                          $1,122.68
48545         Pancreatorrhaphy Inj                                           $1,050.58
48547         Duol Exclusion W/Gastrojejunostomy Pncrtc Inj                  $1,460.91
48550         Don Pncrtect +-Duol Sgm F/Trnsplj                                  $0.00
48552         Bkbench Rcnstj Cdvr Pncrs Algrft Ven Anast Ea                   $230.02
48554         Trnsplj Pncrtc Algrft                                          $2,068.39
48556         Rmvl Trnspled Pncrtc Algrft                                     $963.02
48999         Unlis Px Pncrs                                                     $0.00
49000         Expl Lapt Expl Celiotomy +-Bx Spx                               $690.65
49002         Reopng Recent Lapt                                              $628.15
49010         Expl Rpr Area +-Bx Spx                                          $734.85
49020         Drg Prtl Absc/Loclzd Pritonitis Opn                            $1,289.89
49021         Drg Prtl Absc/Loclzd Pritonitis Prq                             $174.46
49040         Drg Subdiphrg/Subphrenic Absc Opn                               $781.42
49041         Drg Subdiphrg/Subphrenic Absc Prq                               $205.77
49060         Drg Rpr Absc Opn                                                $902.41
49061         Drg Rpr Absc Prq                                                $190.51
49062         Drg Xtrprtl Lymphocele Prtl Cavity Opn                          $677.15
49080         Pritoneocnts Abdl Pcnts/Prtl Lvg 1St                            $207.03
49081         Pritoneocnts Abdl Pcnts/Prtl Lvg Sbsq                           $145.57
49085         Removal Of Peritoneal Foreign Body From Peritoneal Cavity       $698.70
49180         Bx Abdl/Rpr Mass Prq Ndl                                        $189.90
49200         Exc/Dstrj Opn Intra-Abdl/Rpr Csts                                $612.64
49201         Exc/Dstrj Opn Intra-Abdl/Rpr Csts X10Sv                         $884.64
49215         Exc Presac/Sacrococcygeal Tum                                  $1,885.13
49220         Staging Lapt F/Hodgkins Disease/Lymphoma                        $873.20

                                            Page 78
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
49250         Umbilectomy Omphalectomy Exc Umbilicus Spx                      $510.61
49255         Omntc Epiploectomy Rescj Omentum Spx                            $676.81
49300         Peritoneoscopy; Without Biopsy                                  $307.02
49301         Peritoneoscopy; With Biopsy                                     $362.42
49302         Peritoneoscopy With Guided Transhepatic Cholangiography; Wit    $291.85
49303         Peritoneoscopy With Guided Transhepatic Cholangiography; Wit    $355.74
49310         Laparoscopy, Surgical; Cholecystectomy (Any Method)             $759.03
49311         Laparoscopy, Surgical; Cholecystectomy With Cholangiography     $810.21
49315         Laparoscopy, Surgical; Appendectomy                             $444.67
49320         Laps Abd Prtm&Omentum Dx +-Spec Br/Wa Spx                       $310.87
49321         Laps Surg W/Bx 1/Mlt                                            $324.06
49322         Laps Surg W/Aspir Cavity/Cst 1/Mlt                              $349.71
49323         Laps Surg W/Drg Lymphocele Prtl Cavity                          $561.78
49329         Unlis Laps Px Abd Prtm&Omentum                                     $0.00
49400         Njx Air/Cntrst In Prtl Cavity Spx                               $104.33
49401         Pneumoperitoneum (Separate Procedure); Subsequent               $105.51
49419         Insj Ipr Cannula/Cath W/Subq Rsvr Prm                           $404.78
49420         Insj Ipr Cannula/Cath F/Drg/Dial Temp                           $130.30
49421         Insj Ipr Cannula/Cath F/Drg/Dial Prm                            $350.19
49422         Rmvl Prm Ipr Cannula/Cath                                       $370.18
49423         Exchng Absc/Cst Drg Cath Rad Gid Spx                              $82.23
49424         Cntrst Njx Assmt Absc/Cst Via Drg Cath/Tube Spx                   $46.07
49425         Insj Prtl-Ven Shunt                                             $689.51
49426         Revj Prtl-Ven Shunt                                             $580.77
49427         Njx Px F/Eval Previously Placed Prtl-Ven Shunt                    $53.20
49428         Lig Prtl-Ven Shunt                                              $361.09
49429         Rmvl Prtl-Ven Shunt                                             $441.42
49430         Inj Proc Retroperitnl Pneumography                              $145.20
49440         Inj Proc For Pelvic Pneumography                                $145.20
49491         Rpr 1St Ingun Hrna Preterm Inft Rdc                             $654.08
49492         Rpr 1St Ingun Hrna Preterm Inft Ncrc8                           $819.34
49495         Rpr 1St Ingun Hrna Full Term Inft<6 Mo Rdc                      $357.58
49496         Rpr 1St Ingun Hrna Full Term Inft<6 Mo Ncrc8                    $532.57
49500         Rpr 1St Ingun Hrna Age 6 Mo-5 Yrs Rdc                           $341.64
49501         Rpr 1St Ingun Hrna Age 6 Mo-5 Yrs Ncrc8                         $523.45
49505         Rpr 1St Ingun Hrna Age 5 Yrs/> Reducible                        $464.85
49506         Repair Inguinal Hernias                                         $726.00
49507         Rpr 1St Ingun Hrna Age 5 Yrs/> Ncrc8                            $563.43
49510         Repair Inguinal Hernia, Age 5 Or Over; With Orchiectomy, Wit    $477.11
49515         Repair Inguinal Hernia, Age 5 Or Over; With Excision Of Hydr    $480.61
49520         Rpr Recrt Ingun Hrna Any Age Rdc                                $564.25
49521         Rpr Recrt Ingun Hrna Any Age Ncrc8                              $689.86
49525         Rpr Ingun Hrna Sliding Any Age                                  $506.64
49530         Repair Inguinal Hernia, Any Age; Incarcerated                   $512.55
49535         Repair Inguinal Hernia, Any Age; Strangulated                   $606.63
49540         Rpr Lmbr Hrna                                                   $607.19
49550         Rpr 1St Fem Hrna Any Age Rdc                                    $510.38
49551         Repair Femoral Hernias                                         $1,004.30
49552         Repair Femoral Hernia, Henry Approach                           $485.33
49553         Rpr 1St Fem Hrna Any Age Ncrc8                                  $555.65
49555         Rpr Recrt Fem Hrna Rdc                                          $533.20
49557         Rpr Recrt Fem Hrna Ncrc8                                        $646.86
49560         Repair First Abdominal Wall Hernia                              $670.74
49561         Rpr 1St Incal/Vnt Hrna Ncrc8                                    $814.66
49565         Rpr Recrt Incal/Vnt Hrna Rdc                                    $673.30

                                            Page 79
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
49566         Rpr Recrt Incal/Vnt Hrna Ncrc8                                  $823.63
49568         Impltj Mesh/Oth Prosth F/Incal/Vnt Hrna Rpr                      $267.97
49570         Rpr Epigstr Hrna Rdc Spx                                        $353.35
49572         Rpr Epigstr Hrna Ncrc8                                          $407.20
49575         Repair Epigastric Hernia, Properitoneal Fat (Separate Proced    $490.17
49580         Rpr Umbilical Hrna < 5 Yrs Rdc                                  $266.17
49581         Repair Umbilical Hernia; Age 5 Or Over                          $381.83
49582         Rpr Umbilical Hrna <5 Yrs Ncrc8                                 $404.90
49585         Rpr Umbilical Hrna 5 Yrs/> Rdc                                  $380.61
49587         Rpr Umbilical Hrna Age 5 Yrs/> Ncrc8                            $451.67
49590         Rpr Spigelian Hrna                                              $505.52
49600         Rpr Sm Omphalocele W/Prim Clsr                                  $660.64
49605         Rpr Lg Omphalocele/Gastroschisis +-Prosth                      $4,005.88
49606         Rpr Lg Omphalocele/Gastroschisis Rmvl Prosth                   $1,086.15
49610         Rpr Omphalocele Gross Typ Opration 1St Stg                      $621.22
49611         Rpr Omphalocele Gross Typ Opration 2Nd Stg                      $629.16
49630         Reduction Of Torsion, Omentum                                      $0.00
49635         Omentopexy For Establishing Collateral Circulation In Portal       $0.00
49640         Omentoplasty (Omental Flap Reconstruction For Transfer          $423.50
49650         Laps Surg Rpr 1St Ingun Hrna                                    $383.02
49651         Laps Surg Rpr Recrt Ingun Hrna                                  $497.74
49659         Unlis Laps Px Hrnap Herniorrhaphy Herniotomy                       $0.00
49900         Sutr Sec Abdl Wall F/Evsc/Dehsn                                 $747.31
49904         Omental Flap Xtr-Abdl                                          $1,405.96
49905         Omental Flap Intra-Abdl                                         $358.29
49906         Fr Omental Flap W/Mvasc Anast                                      $0.00
49910         Suture Of Omentum, Omentorrhaphy For Wound Or Injury            $423.50
49999         Unlis Px Abd Prtm&Omentum                                          $0.00
50010         Rnl Expl X Necessitating Oth Spec Px                            $645.80
50020         Drg Prirnl/Rnl Absc Opn                                         $907.40
50021         Drg Prirnl/Rnl Absc Prq                                         $173.69
50040         Nfros Nfrot W/Drg                                                $904.83
50045         Nfrot W/Expl                                                     $876.89
50060         Nephrolithotomy Rmvl St1                                       $1,068.47
50065         Nephrolithotomy Sec Surg Opration F/St1                        $1,058.33
50070         Nephrolithotomy Comp Cgen Kdn Abnormality                      $1,124.05
50075         Nephrolithotomy Rmvl Lg Staghorn St1                           $1,390.80
50080         Prq Nephrostolithotomy/Pyelostolithotomy Up 2 Cm                $877.46
50081         Prq Nephrostolithotomy/Pyelostolithotomy > 2 Cm                $1,254.67
50100         Trnsxj/Rpsg Aberrant Rnl Vsl Spx                                $972.36
50120         Plot W/Expl                                                      $898.68
50125         Plot W/Drg Pyelostomy                                           $928.56
50130         Plot W/Rmvl St1                                                  $964.80
50135         Plot Comp                                                      $1,064.20
50200         Rnl Bx Prq Trocar/Ndl                                           $136.76
50205         Rnl Bx Surg Expos Kdn                                           $658.87
50220         Nfrct W/Prtl Urtrec Any Opn Rib Rescj                            $967.87
50225         Nfrct W/Prtl Urtrec Any Opn Rib Rescj Comp                     $1,121.35
50230         Nfrct W/Prtl Urtrec Any Opn Rib Rescj Rad                      $1,211.69
50234         Nfrct W/Tot Urtrec&Bldr Cuff Thru Sm Inc                       $1,232.49
50236         Nfrct Tot Urtrec&Bldr Cuff Thru Sep Inc                        $1,417.02
50240         Nfrct Prtl                                                     $1,270.46
50250         Abltj Opn 1+ Rnl Les Cryosurg W/Intraop Us                     $1,158.24
50280         Exc/Unroofing Cst Kdn                                           $884.36
50290         Exc Prinephric Cst                                              $846.60

                                             Page 80
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                          Amount
50300         Don Nfrct From Cdvr Don Uni/Bi                      $750.20
50320         Don Nfrct Opn From Liv Don                         $1,279.34
50327         Bkbench Rcnstj Rnl Algrft Ven Anast Ea              $213.73
50328         Bkbench Rcnstj Rnl Algrft Artl Anast Ea             $187.20
50329         Bkbench Rcnstj Algrft Urtrl Anast Ea                $178.89
50340         Rcp Nfrct Spx                                       $762.53
50341         Recipient Nephrectomy (Separate Procedure)         $2,117.50
50360         Rnl Altrnsplj Impltj Grf W/O Rcp Nfrct             $1,896.57
50365         Rnl Altrnsplj Impltj Grf W/Rcp Nfrct               $2,221.67
50366         Renal Homotransplantation, Implantation Of Graft   $3,509.00
50370         Rmvl Trnspled Rnl Algrft                            $847.98
50380         Rnl Autotrnsplj Rimpltj Kdn                        $1,346.52
50382         Rmvl&Rplcmt Intly Dwelling Urtrl Stent             $1,583.88
50384         Rmvl Intly Dwelling Urtrl Stent                    $1,529.88
50387         Rmvl&Rplcmt Xtrnlly Accessible Urtrl Stent          $767.13
50389         Rmvl Nfros Tube Req Fluor Gid                       $524.98
50390         Aspir&/Njx Rnl Cst/Pelvis Ndl Prq                   $101.03
50391         Instlj Agt Rnl Pelvis&/Urtr Thru Tube               $138.93
50392         Intro Intracath/Cath In Rnl Pelvis Drg&/Njx Prq     $173.69
50393         Intro Urtrl Cath/Stent Thru Pelvis Drg&/Njx Prq     $213.20
50394         Njx Px Plog Thru Tube/Cath                          $123.16
50395         Intro Gd Pelvis&/Urtr W/Dilat Nfros Trc              $173.73
50396         Manometric Stds Thru Tube/Ndwellg Urtrl Cath        $114.32
50398         Chng Nfros/Pyelostomy Tube                          $101.22
50400         Plop Rnl Pelvis Smpl                               $1,068.28
50405         Plop Rnl Pelvis Comp                               $1,343.34
50420         Nephropexy,Fixation Or Suspnsn Kidney              $1,113.20
50500         Nephrorrhaphy Sutr Kdn Wnd/Inj                     $1,121.04
50520         Clsr Nephrocutan/Pyelocutan Fstl                   $1,023.58
50525         Clsr Nephrovisc Fstl W/Visc Rpr Abdl Appr          $1,275.46
50526         Clsr Nephrovisc Fstl W/Visc Rpr Thrc Appr          $1,372.01
50540         Symphysiotomy Horseshoe Kdn +-Plop Uni/Bi          $1,117.90
50541         Laps Abltj Rnl Csts                                 $879.15
50542         Laps Abltj Rnl Mass Les                            $1,109.25
50543         Laps Prtl Nfrct                                    $1,392.37
50544         Laps Plop                                          $1,213.71
50545         Laps Radical Nfrct                                 $1,302.92
50546         Laps Nfrct W/Prtl Urtrec                           $1,133.78
50547         Laps Don Nfrct From Liv Don                        $1,431.95
50548         Laps Nfrct W/Tot Urtrec                            $1,315.46
50549         Unlis Laps Px Rnl                                      $0.00
50551         Rnl Ndsc Nfros/Pyelostomy                           $404.65
50553         Rnl Ndsc Nfros/Pyelostomy Urtrl Cathj               $919.20
50555         Rnl Ndsc Nfros/Pyelostomy Bx                        $962.17
50557         Rnl Ndsc Nfros/Pyelostomy Fulg&/Inc +-Bx            $997.71
50559         Renal Endoscopy/Radiotracer                         $346.17
50561         Rnl Ndsc Nfros/Pyelostomy Rmvl Fb/St1               $950.55
50562         Rnl Ndsc Nfros/Pyelostomy Rescj Tum                 $588.30
50570         Rnl Ndsc Nfrot/Plot                                 $495.24
50572         Rnl Ndsc Nfrot/Plot W/Urtrl Cathj +-Dilat Urtr      $538.63
50574         Rnl Ndsc Nfrot/Plot Bx                              $572.82
50575         Rnl Ndsc Nfrot/Plot W/Endoplot                      $725.93
50576         Rnl Ndsc Nfrot Fulguration&/Inc +-Bx                $570.32
50578         Renal Endoscopy/Radiotracer                         $588.92
50580         Rnl Ndsc Nfrot/Plot W/Rmvl Fb/St1                    $615.02

                                             Page 81
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
50590         Lithotrp Xtrcorp Shock Wave                                      $758.75
50592         Abltj 1+ Rnl Tum Prq Uni Rf                                    $5,891.70
50600         Urtrotomy W/Expl/Drg Spx                                         $894.35
50605         Urtrotomy F/Insj Ndwellg Stent All Typs                          $887.45
50610         Urtrolithotomy Upr One-3Rd Urtr                                  $910.95
50620         Urtrolithotomy Middle One-3Rd Urtr                              $851.79
50630         Urtrolithotomy Lwr One-3Rd Urtr                                  $840.98
50650         Urtrec W/Bldr Cuff Spx                                           $975.29
50660         Urtrec Tot Ectopic Urtr Cmbn Appr                              $1,088.32
50684         Njx Urtrg/Urtroplog Thru Urtrost/Urtrl Cath                      $592.03
50686         Manometric Stds Thru Urtrost/Ndwellg Urtrl Cath                 $227.37
50688         Chng Urtrost Tube/Xtrnlly Accessible Stent Ileal                $110.44
50690         Njx Visualization Ileal Conduit&/Urtroplog                      $624.57
50700         Urtroplasty Plstc Opration Urtr                                  $876.05
50715         Urtrolss +-Rpsg Urtr F/Rpr Fibrosis                            $1,116.91
50716         Ureterolysis, With Or Without Repositioning Of Ureter For      $1,694.00
50722         Urtrolss F/Ovarian Vein Synd                                     $972.13
50725         Urtrolss Retrocaval Urtr W/Reanast                             $1,063.51
50727         Revj Ur-Cutan Anast                                              $520.16
50728         Revj Ur-Cutan Anast Rpr Fscal Dfct&Hrna                          $736.58
50740         Urtropyelostomy Anast Urtr&Rnl Pelvis                          $1,050.56
50750         Urtrocalycostomy Anast Urtr Rnl Calyx                          $1,090.37
50760         Urtrourtrost                                                   $1,038.39
50770         Transurtrourtrost Anast Urtr Clat Urtr                         $1,090.04
50780         Urtroneocstost Anast 1 Urtr Bldr                               $1,030.42
50781         Ureteroneocystostomy, Anastomosis Of Ureter To Bladder,        $1,815.00
50782         Urtroneocstost Anast Duplicated Urtr Bldr                      $1,142.75
50783         Urtroneocstost W/X10Sv Urtrl Tailoring                         $1,173.93
50785         Urtroneocstost W/Vesico-Psoas Hitch/Bldr Flap                  $1,142.25
50786         Ureteroneocystostomy, With Bladder Flap                        $1,996.50
50800         Urtrontrstm Dir Anast Urtr Int                                   $841.81
50801         Ureteroenterostomy, Direct Anastomosis Of Ureter To Intestin   $1,815.00
50810         Urtrosigmoidostomy Crtj Clst Int Anast                         $1,184.45
50815         Urtrocolon Conduit Int Anast                                   $1,133.40
50816         Ureterocolon Conduit, Including Bowel Anastomosis                  $0.00
50820         Urtroileal Conduit W/Int Anast                                 $1,217.51
50821         Ureteroileal Conduit (Ileal Bladder), Including Bowel          $2,420.00
50825         Continent Dvrj W/Int Anast W/Any Sgm Sm&/Lg Int                $1,564.81
50830         Ur Undvrj                                                      $1,736.19
50840         Rplcmt All/Part Urtr Int Sgm W/Int Anast                       $1,133.58
50841         Replacement Of All Or Part Of Ureter By Bowel Segment, Inclu   $2,783.00
50845         Cutan Appendico-Vesicostomy                                    $1,164.62
50860         Urtrost Trnsplj Urtr Skn                                         $874.00
50861         Ureterostomy, Transplantation Of Ureter To Skin                $1,573.00
50900         Urtrorrhaphy Sutr Urtr Spx                                       $788.05
50920         Clsr Urtrocutan Fstl                                             $823.35
50930         Clsr Urtrovisc Fstl W/Visc Rpr                                 $1,073.82
50940         Delig Urtr                                                       $833.99
50945         Laps Urtrolithotomy                                              $944.34
50947         Laps Urtroneocstost W/Cstsc&Urtrl Stent Plmt                   $1,363.69
50948         Laps Urtroneocstost W/O Cstsc&Urtrl Stent Plmt                 $1,243.68
50949         Unlis Laps Px Urtr                                                 $0.00
50951         Ndsc Thru Urtrost                                                $429.77
50953         Ndsc Urtrost W/Urtrl Cathj                                       $930.49
50955         Ndsc Thru Urtrost Bx                                           $1,019.32

                                             Page 82
                           MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
50957         Ndsc Thru Urtrost Fulg&/Inc +-Bx                              $939.46
50959         Ureter Endoscopy/Radiotracer                                  $222.89
50961         Ndsc Thru Urtrost Rmvl Fb/St1                                $1,172.67
50970         Ndsc Thru Urtrotomy                                           $371.37
50972         Ndsc Thru Urtrotomy Urtrl Cathj +-Dilat                       $358.90
50974         Ndsc Thru Urtrotomy Bx                                        $475.05
50976         Ndsc Thru Urtrotomy Fulg&/Inc +-Bx                            $469.46
50978         Ureter Endoscopy/Radiotracer                                  $265.68
50980         Ndsc Thru Urtrotomy Rmvl Fb/St1                               $355.66
51000         Aspir Bldr Ndl                                                $103.87
51005         Aspir Bldr Trocar/Intracath                                   $217.43
51010         Aspir Bldr W/Insj Suprapubic Cath                             $352.42
51020         Cstotomy/Cstost Fulg&/Insj Radact Matrl                       $416.25
51030         Cstotomy/Cstost Cryosurg Dstrj Intravesical Les               $422.51
51040         Cstost Cstotomy W/Drg                                         $282.14
51045         Cstotomy W/Insj Urtrl Cath/Stent Spx                           $423.85
51050         Cstolithotomy Cstotomy W/Rmvl St1                             $415.69
51060         Transvesical Urtrolithotomy                                   $525.22
51065         Cstotomy W/St1 Basket Xtrj&/Fragmentation                     $519.34
51080         Drg Privesical/Prevesical Space Absc                          $372.90
51500         Exc Urachal Cst/Sinus +-Umbilical Hrna Rpr                    $606.50
51520         Cstotomy F/Smpl Exc Vesical Nck Spx                           $549.89
51525         Cstotomy F/Exc Bldr Diverticulum 1/Mlt Spx                    $791.00
51530         Cstotomy F/Exc Bldr Tum                                        $716.13
51535         Cstotomy F/Exc Inc/Rpr Urtrocele                              $740.44
51536         Cystotomy For Excision, Incision, Or Repair Of Ureterocele   $1,270.50
51550         Cstc Prtl Smpl                                                $886.14
51555         Cstc Prtl Comp                                               $1,180.41
51565         Cstc Prtl W/Rimpltj Urtr In Bldr Urtroneocstost              $1,207.92
51570         Cstc Compl Spx                                               $1,344.67
51575         Cstc Compl W/Bi Pel Lmphadec                                 $1,675.13
51580         Cstc Compl W/Trnspljs                                        $1,718.66
51585         Cstc Compl W/Trnspljs W/Lmphadec                             $1,929.23
51590         Cstc Compl W/Urtroileal Conduit/Bldr W/Int Anast             $1,784.93
51595         Cstc Compl W/Conduit/Sigmoid Bldr Pel Lmphadec               $2,018.32
51596         Cstc Compl W/Continent Dvrj Opn Neobldr                      $2,155.45
51597         Pel Exntj Compl Mal                                          $2,102.04
51600         Njx Cstograpy/Voiding Urethrocstograpy                        $248.51
51605         Njx&Plmt Chain C+&/Urethrocstograpy                           $420.30
51610         Njx Rtrgr Urethrocstograpy                                    $433.10
51700         Bldr Irrigation Smpl Lvg&/Instlj                                $95.55
51701         Insj Non-Ndwellg Bldr Cath                                      $80.18
51702         Insj Temp Ndwellg Bldr Cath Smpl                              $105.74
51703         Insj Temp Ndwellg Bldr Cath Comp                              $170.74
51705         Chng Cstost Tube Smpl                                         $126.38
51710         Chng Cstost Tube Comp                                         $185.36
51715         Ndsc Njx Implt Matrl Urt&/Bldr Nck                            $297.50
51720         Bldr Instlj Anticarcinogenic Agt                              $144.24
51725         Smpl Cstometrogram                                            $273.59
51725   26    Smpl Cstometrogram                                              $77.95
51725   TC    Smpl Cstometrogram                                            $195.64
51726         Bladder Pressure Measurement During Filling                   $357.46
51726   26    Bladder Pressure Measurement During Filling                     $88.19
51726   TC    Bladder Pressure Measurement During Filling                   $269.27
51736         Smpl Uroflometry                                                $46.40

                                              Page 83
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                   Amount
51736    26   Smpl Uroflometry                                               $31.92
51736   TC    Smpl Uroflometry                                               $14.48
51739         Sound Recording Of External Stream (Eg, Lyons Type, Keitzer    $66.69
51739   26    Sound Recording Of External Stream (Eg, Lyons Type, Keitzer    $20.01
51739   TC    Sound Recording Of External Stream (Eg, Lyons Type, Keitzer    $46.68
51741         Cplx Uroflometry                                               $75.85
51741   26    Cplx Uroflometry                                               $59.12
51741   TC    Cplx Uroflometry                                               $16.73
51751         Cont Wave Or Puls Doppler During Urintn 1 Void                  $0.00
51751   26    Cont Wave Or Puls Doppler During Urintn 1 Void                  $0.00
51751   TC    Cont Wave Or Puls Doppler During Urintn 1 Void                  $0.00
51752         Cont Wave/Puls Vodng Urintn/Void;Addtnl Voidng                  $0.00
51752   26    Cont Wave/Puls Vodng Urintn/Void;Addtnl Voidng                  $0.00
51752   TC    Cont Wave/Puls Vodng Urintn/Void;Addtnl Voidng                  $0.00
51753         Cont Wave/Puls Dopplr Urintn; Add Transdcis/Void                $0.00
51753   26    Cont Wave/Puls Dopplr Urintn; Add Transdcis/Void                $0.00
51753   TC    Cont Wave/Puls Dopplr Urintn; Add Transdcis/Void                $0.00
51754         Cont Wave/Puls Dopplr Urintn;Add Trnsdcr,Add Vds                $0.00
51754   26    Cont Wave/Puls Dopplr Urintn;Add Trnsdcr,Add Vds                $0.00
51754   TC    Cont Wave/Puls Dopplr Urintn;Add Trnsdcr,Add Vds                $0.00
51755         Cont Wave/Puls Dopplr Urintn;Bfr/Aftr Phrmclogcl                $0.00
51755   26    Cont Wave/Puls Dopplr Urintn;Bfr/Aftr Phrmclogcl                $0.00
51755   TC    Cont Wave/Puls Dopplr Urintn;Bfr/Aftr Phrmclogcl                $0.00
51756         Cont Wave/Puls Dopplr Urintn;Bfr/Aftr Nrv Blck                  $0.00
51756   26    Cont Wave/Puls Dopplr Urintn;Bfr/Aftr Nrv Blck                  $0.00
51756   TC    Cont Wave/Puls Dopplr Urintn;Bfr/Aftr Nrv Blck                  $0.00
51758         Rotating Scan Doppler During Urination                          $0.00
51758   26    Rotating Scan Doppler During Urination                          $0.00
51758   TC    Rotating Scan Doppler During Urination                          $0.00
51759         Rotatng Scan Dopplr Ding Urintn;Add Voidng                      $0.00
51759   26    Rotatng Scan Dopplr Ding Urintn;Add Voidng                      $0.00
51759   TC    Rotatng Scan Dopplr Ding Urintn;Add Voidng                      $0.00
51761         Acoustcl Mea. Ureth Urintn;1 Void, 1 Trnsdcr                    $0.00
51761   26    Acoustcl Mea. Ureth Urintn;1 Void, 1 Trnsdcr                    $0.00
51761   TC    Acoustcl Mea. Ureth Urintn;1 Void, 1 Trnsdcr                    $0.00
51762         Acoustcl Mea.Ureth;Add Voidng, 1 Trnsdcr                        $0.00
51762   26    Acoustcl Mea.Ureth;Add Voidng, 1 Trnsdcr                        $0.00
51762   TC    Acoustcl Mea.Ureth;Add Voidng, 1 Trnsdcr                        $0.00
51763         Acoustcl Mea.Urethr Urntn;Add Trnsdcrs,1 Void                   $0.00
51763   26    Acoustcl Mea.Urethr Urntn;Add Trnsdcrs,1 Void                   $0.00
51763   TC    Acoustcl Mea.Urethr Urntn;Add Trnsdcrs,1 Void                   $0.00
51764         Acustcl Mea Urthr Urintn;Add Trnsdcrs,Add Voids                 $0.00
51764   26    Acustcl Mea Urthr Urintn;Add Trnsdcrs,Add Voids                 $0.00
51764   TC    Acustcl Mea Urthr Urintn;Add Trnsdcrs,Add Voids                 $0.00
51765         Acstcl Mea.Urethr Urintn;Bfr/Aftr Phrmclgcl Tst                 $0.00
51765   26    Acstcl Mea.Urethr Urintn;Bfr/Aftr Phrmclgcl Tst                 $0.00
51765   TC    Acstcl Mea.Urethr Urintn;Bfr/Aftr Phrmclgcl Tst                 $0.00
51766         Acstcl Mea Urethr Urintn;Bfr/Aftr Nerv Blck                     $0.00
51766   26    Acstcl Mea Urethr Urintn;Bfr/Aftr Nerv Blck                     $0.00
51766   TC    Acstcl Mea Urethr Urintn;Bfr/Aftr Nerv Blck                     $0.00
51768         Urthrl Fluid Condctn Mea.Urintn; 1 Loc., 1 Void                 $0.00
51768   26    Urthrl Fluid Condctn Mea.Urintn; 1 Loc., 1 Void                 $0.00
51768   TC    Urthrl Fluid Condctn Mea.Urintn; 1 Loc., 1 Void                 $0.00
51769         Urthrl Fluid Condctnc Mea. Urintn;Add. Loc.                     $0.00
51769   26    Urthrl Fluid Condctnc Mea. Urintn;Add. Loc.                     $0.00

                                            Page 84
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                      Amount
51769   TC    Urthrl Fluid Condctnc Mea. Urintn;Add. Loc.        $0.00
51772         Urtl Press Profile Stds                         $278.91
51772   26    Urtl Press Profile Stds                           $84.62
51772   TC    Urtl Press Profile Stds                         $194.29
51784         Emg Stds Anal/Urtl Sphnctr Oth/Thn Ndl          $213.72
51784   26    Emg Stds Anal/Urtl Sphnctr Oth/Thn Ndl            $79.23
51784   TC    Emg Stds Anal/Urtl Sphnctr Oth/Thn Ndl          $134.49
51785         Ndl Emg Stds Emg Anal/Urtl Sphnctr Any Tq       $231.93
51785   26    Ndl Emg Stds Emg Anal/Urtl Sphnctr Any Tq         $78.79
51785   TC    Ndl Emg Stds Emg Anal/Urtl Sphnctr Any Tq       $153.14
51792         Stimulus Evoked Rspse                           $269.20
51792   26    Stimulus Evoked Rspse                             $59.57
51792   TC    Stimulus Evoked Rspse                           $209.63
51795         Voiding Press Stds Bldr Voiding Press Any Tq    $344.33
51795   26    Voiding Press Stds Bldr Voiding Press Any Tq      $79.02
51795   TC    Voiding Press Stds Bldr Voiding Press Any Tq    $265.31
51797         Voiding Press Stds Intra-Abdl Voiding Press     $283.93
51797   26    Voiding Press Stds Intra-Abdl Voiding Press       $82.40
51797   TC    Voiding Press Stds Intra-Abdl Voiding Press     $201.53
51798         Meas Post-Voiding Residual Urine&/Bldr Cap        $16.40
51800         Cstoplasty/Cstourtp Plstc Any                   $987.49
51820         Cstourtp W/Uni/Bi Urtroneocstost               $1,046.99
51840         Ant Vesicourethropexy/Urethropexy Smpl          $645.26
51841         Ant Vesicourethropexy/Urethropexy Comp          $769.24
51845         Abdomino-Vag Vesical Nck Ssp +-Ndsc Ctrl        $571.28
51860         Cstorr Sutr Bldr Wnd Inj/Rpt Smpl               $707.04
51865         Cstorr Sutr Bldr Wnd Inj/Rpt Comp               $859.86
51880         Clsr Cstost Spx                                 $460.70
51900         Clsr Vesicovag Fstl Abdl Appr                   $753.38
51920         Clsr Vesicouterine Fstl                         $692.50
51925         Clsr Vesicouterine Fstl W/Hyst                  $968.59
51940         Clsr Exstrophy Bldr                            $1,608.21
51960         Enterocstoplasty W/Intstinal Anast             $1,287.61
51980         Cutan Vesicostomy                               $660.10
51990         Laps Surg Urtl Ssp F/Strs Incont                $741.70
51992         Laps Surg Sling Opration F/Strs Incont          $795.79
52000         Scope Of Bladder And Urethra, For Diagnosis     $204.17
52001         Csto W/Irrg&Evac Mlt Obstructing Clots          $408.14
52005         Scope Bladder, Insert Tube For Injection        $314.18
52007         Csto W/Urtrl Cathj Brush Bx Urtr&/Rnl Pelvis    $163.71
52010         Csto W/Ejaculatory Dux Cathj                    $162.98
52190         Diffrntl Quantitr & Chemcl Renl Functn Test     $338.80
52204         Scope Bladder And Urethra, With Biopsy          $228.37
52214         Scope Bladder, Destruction Of Lesions           $197.70
52222         Cystoscopy And Treatment                        $193.60
52224         Scope Bladder, Removal Of Lesions, Small        $168.19
52234         Scope Bladder, Removal Of Tumors,Small          $245.45
52235         Scope Bladder, Removal Of Tumors, Medium        $288.37
52240         Scope Bladder, Removal Of Tumors, Large         $511.54
52250         Csto Insj Radact Sbst +-Bx/Fulg                 $241.69
52260         Scope Bladder, Opening Of Bladder               $209.60
52265         Csto Dilat Bldr F/Ntrstl Cstitis Local Anes     $255.66
52270         Csto Int Urethrotomy Female                     $180.87
52275         Csto Int Urethrotomy Male                       $249.93
52276         Csto Dir Vis Int Urethrotomy                    $266.33

                                             Page 85
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
52277         Csto Rescj Xtrnl Sphnctr                                        $331.25
52281         Csto Calibration Dilat Urtl Strix/Stenosis                      $384.40
52282         Csto Insj Urtl Stent                                            $339.10
52283         Csto Strd Njx In Strix                                          $297.42
52285         Scope Bladder, Open Narrowed Female Urethra                     $295.12
52290         Csto Urtrl Meatotomy Uni/Bi                                     $245.05
52300         Csto Orthotopic Urtrocele Uni/Bi                                $283.51
52301         Csto Ectopic Urtrocele Uni/Bi                                   $297.52
52305         Csto Inc/Rescj Orifice Bldr Diverticulum 1/Mlt                  $280.87
52310         Scope Bladder, Simple Removal Stone, Stent                      $242.37
52315         Scope Bladder, Complex Removal Stone, Stent                     $276.40
52317         Litholapaxy Smpl/Sm < 2.5 Cm                                    $353.33
52318         Litholapaxy Comp/Lg > 2.5 Cm                                    $482.41
52320         Csto Rmvl Urtrl St1                                             $248.84
52325         Csto Fragmentation Urtrl St1                                    $324.99
52327         Csto W/Suburtric Njx Implt Matrl                                $276.10
52330         Csto Mnpj W/O Rmvl Urtrl St1                                    $266.73
52332         Scope Bladder & Ureter, Insert Stent Into Ureter                $152.92
52334         Csto Insj Urtrl Gd Wire Prq Nfros Rtrgr                         $258.07
52335         Cystourethroscopy W/Ureteroscopy                                $364.34
52336         Cystourethroscpy; W/Remov Calcu                                 $498.97
52337         Cystourethroscopy; W/Lith                                       $575.44
52338         Cystourethroscpy W/Uretroscpy; W/Bx                             $457.38
52339         Cystourethroscopy; W/Resect Tumor                               $512.49
52340         Cysturethroscpy W/Resect Ureth Valv                             $566.08
52341         Csto W/Tx Urtrl Strix                                           $323.03
52342         Csto W/Tx Urtropel Junct Strix                                  $347.67
52343         Csto W/Tx Intra-Rnl Strix                                       $384.60
52344         Csto W/Urtroscopy W/Tx Urtrl Strix                              $412.57
52345         Csto W/Urtroscopy W/Tx Urtropel Junct Strix                     $438.30
52346         Csto W/Urtroscopy W/Tx Intra-Rnl Strix                          $492.47
52347         Cysturthscopy W/Transureth Resect                               $275.49
52351         Csto W/Urtroscopy&/Pyeloscopy Dx                                $314.07
52352         Scope Bladder & Ureter, Remove Or Move Stones                   $368.92
52353         Scope Bladder & Ureter, Break Up Kidney Stone                   $425.65
52354         Csto/Pyeloscopy Bx&/Fulg Pel Les                                $393.16
52355         Csto/Pyeloscopy Rescj Pel Tum                                   $470.83
52400         Csto Inc Fulg/Rescj Urtl Valves/Folds                           $528.39
52402         Csto W/Trurl Rescj/Inc Ejaculatory Duxs                         $279.38
52450         Trurl Inc Prst8                                                 $442.74
52500         Surgery On Bladder Neck Through Urethra                         $484.90
52510         Trurl Balo Dilat Prostatic Urt                                  $384.73
52601         Trurl Electrosurg Rescj Prst8 Ctrl Bld Compl                    $685.40
52606         Trurl Fulg Po Bld Occurring After F-Up                          $457.92
52612         Trurl Rescj Prst8 1St Stg 2-Stg Rescj                           $458.85
52614         Trurl Rescj Prst8 2Nd Stg 2-Stg Rescj                           $398.38
52620         Trurl Rescj Obstr Tiss After 90 D Po                            $375.47
52630         Trurl Rescj Regrowth Obstr 1 Yr Po                              $409.44
52640         Opening Of Postoperative Bladder Neck Narrowing                 $374.75
52647         Laser Coagulation Of Prostate For Urine Flow                   $2,121.85
52648         Laser Vaporization Of Prostate For Urine Flow                   $627.10
52650         Transurethral Cryosurgical Removal Of Prostate (Postoperativ    $729.76
52700         Trurl Drg Prostatic Absc                                        $390.68
52805         Lthlpxy Crshng Calcls Blddr&Rmvl Fragmnts;Lg                    $968.00
53000         Urtt/Urts Xtrnl Spx Pendulous Urt                               $148.97

                                             Page 86
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
53010         Urtt/Urts Xtrnl Spx Prnl Urt Xtrnl                              $255.58
53020         Meatotomy Cutting Meatus Spx Xcp Inft                           $184.58
53025         Meatotomy Cutting Meatus Spx Inft                               $186.76
53040         Drg Dp Priurtl Absc                                             $670.43
53060         Drg Of Skene's Gland Absc Or Cyst                               $162.54
53080         Drg Prnl Ur Xtrvasation Uncomp Spx                              $480.54
53085         Drg Prnl Ur Xtrvasation Comp                                    $694.29
53200         Bx Urt                                                          $261.90
53210         Urethrectomy Tot W/Cstost Female                                $726.83
53215         Urethrectomy Tot W/Cstost Male                                  $873.76
53220         Exc/Fulguration Carc Urt                                        $422.78
53230         Exc Urtl Diverticulum Spx Female                                $563.36
53235         Exc Urtl Diverticulum Spx Male                                  $590.47
53240         Marsupialization Urtl Diverticulum Male/Female                  $394.13
53250         Exc Of Bulbourtl Gland                                          $360.06
53260         Exc/Fulguration Urtl Polyp Dstl Urt                             $242.43
53265         Exc/Fulguration Urtl Caruncle                                   $193.45
53270         Exc Or Fulguration Skene's Glands                               $193.83
53275         Exc/Fulguration Urtl Prolapse                                   $265.86
53400         Urtp 1St Stg F/Fstl Diverticulum/Strix                          $740.72
53405         Urtp 2Nd Stg W/Ur Dvrj                                          $820.19
53410         Urtp One-Stg Rcnstj Male Ant Urt                                $924.43
53415         Urtp Transpubic/Prnl 1 Stg Rcnstj/Rpr Urt                      $1,053.35
53420         Urtp 2-Stg Rcnstj/Rpr Urt 1St Stg                               $804.85
53425         Urtp 2-Stg Rcnstj/Rpr Urt 2Nd Stg                               $900.96
53430         Urtp Rcnstj Female Urt                                          $919.36
53431         Urtp W/Tubularization Post Urt&/Lwr Bldr                       $1,103.75
53440         Sling Opration Corrj Male Ur Incont                             $764.16
53442         Rmvl/Revj Sling Male Ur Incont                                  $659.31
53443         Urethroplasty W/Tubulariz Urethra                              $1,173.96
53444         Insj Tandem Cuff                                                $758.52
53445         Insj Nfltbl Urtl/Bldr Nck Sphnctr                               $830.43
53446         Rmvl Nfltbl Urtl/Bldr Nck Sphnctr                               $606.62
53447         Rmvl&Rplcmt Nfltbl Nck Sphnctr Sm Sess                          $778.22
53448         Rmvl&Rplcmt Nfltbl Nck Sphnctr Thru Infct Fld                  $1,190.33
53449         Rpr Nfltbl Urtl/Bldr Nck Sphnctr                                $566.98
53450         Urethromeatoplasty W/Mucosal Advmnt                             $371.35
53460         Urethromeatoplasty W/Prtl Exc Dstl Urtl Sgm                     $426.12
53500         Urethrolss Trvg Sec Opn W/Csto                                  $717.40
53502         Urtorr Sutr Urtl Wnd/Inj Female                                 $459.01
53505         Urtorr Sutr Urtl Wnd/Inj Pen                                    $452.59
53510         Urtorr Sutr Urtl Wnd/Inj Prnl                                   $599.21
53515         Urtorr Sutr Urtl Wnd/Inj Prostatomembranous                     $757.83
53520         Clsr Urethrostomy/Urethroq Fstl Male Spx                        $517.74
53600         Dilat Urtl Strix Dilator Male 1St                                 $91.16
53601         Dilat Urtl Strix Dilator Male Sbsq                                $86.91
53605         Dilat Urtl Strix/Vesical Nck Dilator Male Anes                    $66.83
53620         Dilat Urtl Strix Filiform&Follwr Male 1St                       $139.86
53621         Dilat Urtl Strix Filiform&Follwr Male Sbsq                      $132.25
53640         Passage Of Filiform And Follower For Acute Vesical Retention      $91.51
53660         Dilat Female Urt W/Suppository&/Instlj 1St                        $77.48
53661         Dilat Female Urt W/Suppository&/Instlj Sbsq                       $77.85
53665         Dilat Female Urt General/Cndj Spi Anes                            $40.31
53670         Insert Urinary Catheter                                           $61.00
53675         Insert Urinary Catheter                                         $192.66

                                             Page 87
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
53800         Two Or Three Glass Test Including Examination Of Urine Speci       $6.93
53850         Trurl Dstrj Prst8 Tiss Microwave Thermoth                      $3,952.86
53852         Trurl Dstrj Prst8 Tiss Rf Thermoth                             $3,794.46
53853         Trurl Dstrj Prst8 Tiss Water-Induced Thermoth                  $2,322.25
53899         Unlis Px Ur Sys                                                    $0.00
54000         Slitting Prepuce Dorsal/Lat Spx Nb                              $110.95
54001         Slitting Prepuce Dorsal/Lat Spx Xcp Nb                          $245.71
54015         I&D Pns Dp                                                      $309.12
54050         Dstrj Les Pns Smpl Chem                                         $111.27
54055         Dstrj Les Pns Smpl Eltrdsiccation                               $107.23
54056         Dstrj Les Pns Smpl Cryosurg                                     $139.71
54057         Dstrj Les Pns Smpl Laser Surg                                     $82.14
54060         Dstrj Les Pns Smpl Surg Exc                                     $219.44
54065         Dstrj Les Pns X10Sv                                             $159.68
54100         Bx Pns Spx                                                      $180.63
54105         Bx Pns Dp Struxs                                                $212.05
54110         Exc Pen Plaque                                                  $612.73
54111         Exc Pen Plaque Grf 5 Cm Length                                  $788.88
54112         Exc Pen Plaque Grf > 5 Cm Length                                $918.22
54115         Rmvl Fb From Dp Pen Tiss                                        $559.86
54120         Amp Pns Prtl                                                    $605.67
54125         Amp Pns Compl                                                   $790.79
54130         Amp Pns Rad W/Bi Inguinofem Lmphadec                           $1,141.76
54135         Amp Pns Rad Bi Pel Lmphadec                                    $1,465.78
54150         Circumcision W/Clamp/Oth Dev W/Block                            $111.55
54152         Circumcision, Using Clamp Or Other Device; Except Newborn       $137.80
54160         Circumcision Neonate                                            $140.86
54161         Circumcision >28 Days                                           $189.19
54162         Lss/Exc Pen Post-Circumcision Ads                               $194.81
54163         Rpr Incompl Circumcision                                        $195.18
54164         Frenulotomy Pns                                                 $168.63
54200         Njx Peyronie                                                    $109.98
54205         Njx Peyronie Expos Plaque                                       $495.28
54220         Irrg C/P/A Cavernosa F/Priapism                                 $241.56
54230         Njx F/C/P/A Cavernosograpy                                        $95.00
54231         Dynamic Cavernosometry Njx Vasoactive Drugs                     $134.21
54235         Njx C/P/A Cavernosa W/Pharmacologic Agt                           $83.47
54240         Pen Plethysmograpy                                                $92.30
54240   26    Pen Plethysmograpy                                                $68.11
54240   TC    Pen Plethysmograpy                                                $24.19
54250         Nocturnal Pen Tumescence&/Rgdity Tst                            $124.58
54250   26    Nocturnal Pen Tumescence&/Rgdity Tst                            $115.62
54250   TC    Nocturnal Pen Tumescence&/Rgdity Tst                               $8.96
54300         Pns Straightening Chordee                                       $629.24
54304         Pns Corrj Chordee 1St Stg Hypspad Rpr                           $740.63
54305         W/Transplatation Of Prepuce                                     $968.00
54308         Urtp 2Nd Stg Hypspad Rpr < 3 Cm                                 $700.44
54312         Urtp 2Nd Stg Hypspad Rpr > 3 Cm                                 $808.72
54316         Urtp 2Nd Stg Hypspad Rpr Skn Grf                                $973.74
54318         Urtp 3Rd Stg Hypspad Rpr Rls Pns                                $694.96
54320         Urethroplasty, Form/Urethra,Denis-Brown Type                    $968.00
54322         1 Stg Dstl Hypspad Rpr W/Smpl Meatal Advmnt                     $764.96
54324         1 Stg Dstl Hypspad Rpr W/Urtp Skn Flaps                         $958.85
54325         Dennis-Brown Type;Scrotal/Perineal                             $1,270.50
54326         1 Stg Dstl Hypspad Rpr Urtp Skn Flaps&Moblj                     $923.91

                                            Page 88
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
54328         1 Stg Dstl Hypspad Rpr W/X10Sv Dsj                              $900.80
54330         Urethroplasy/Straigt/Chordee, 1 Stage,/ Hyposp                 $1,391.50
54332         1 Stg Prox Pen/Penoscrotal Hypspad Rpr                          $975.83
54336         1 Stg Prnl Hypspad Rpr Req X10Sv Dsj Skn Grf                   $1,231.41
54340         Rpr Hypspad Complctjs Clsr Inc/Exc Smpl                         $559.42
54344         Rpr Hypspad Complctjs Moblj Flaps&Urtp                          $939.57
54348         Rpr Hypspad Complctjs X10Sv Dsj&Urtp Flap/Grf                  $1,003.31
54352         Rpr Hypspad Cripple Req X10Sv Dsj&Exc                          $1,421.53
54360         Plstc Pns Correct Angulation                                    $706.13
54380         Plstc Pns Epspad Dstl Sphnctr                                    $797.74
54385         Plstc Pns Epspad Dstl Sphnctr W/Incont                           $918.90
54390         Plstc Pns Epspad Dstl Sphnctr W/Exstrophy Bldr                 $1,219.33
54400         Insj Pen Prosth Non-Nfltbl Semi-Rgd                             $524.56
54401         Insj Pen Prosth Nfltbl Self-Contained                           $626.09
54402         Remov/Replac Penile Prosth                                      $606.83
54405         Insj Multi-Component Nfltbl Pen Prosth                          $761.05
54406         Rmvl Nfltbl Pen Prosth W/O Rplcmt Prosth                         $687.04
54407         Remov/Repr/Replac Penile Prosth                                 $866.28
54408         Rpr Component Multi-Component Nfltbl Pen Prosth                 $724.67
54409         Surg Correct Hydraulic Abnl-Prosth                              $790.00
54410         Rmvl&Rplcmt Nfltbl Pen Prosth Sm Sess                           $868.39
54411         Rmvl&Rplcmt Nfltbl Pen Prosth Thru Infct Fld                     $894.62
54415         Rmvl Non-Nfltbl/Nfltbl Pen Prosth W/O Rplcmt                    $486.34
54416         Rmvl&Rplcmt Non-Nfltbl/Nfltbl Prosth Sm Sess                    $629.52
54417         Rmvl&Rplcmt Non-Nfltbl/Nfltbl Pen Infct Sm Sess                 $782.70
54420         C/P/A Cavernosa-Saphenous Vein Shunt Uni/Bi                     $669.56
54430         C/P/A Cavernosa-Corpus Spongiosum Shunt Uni/Bi                  $599.24
54435         C/P/A Cavernosa-Glans Pns Fstlj F/Priapism                      $381.84
54440         Plstc Opration Pns F/Inj                                         $363.00
54450         Foreskn Mnpj W/Lss Preputial Ads&Stretching                       $85.61
54500         Bx Tstis Ndl Spx                                                  $75.26
54505         Bx Tstis Incal Spx                                               $209.46
54506         Biopsy Of Testis, Incisional (Separate Procedure)               $278.30
54510         Exc Local Les Testis                                             $347.99
54512         Exc Xtrparenchymal Les Tstis                                     $499.20
54520         Orchiectomy Smpl Scrotal/Ingun Appr                             $315.25
54521         Orchiectomy, Simple (Including Subcapsular), With Or Without    $568.70
54522         Orchiectomy Prtl                                                 $564.15
54530         Orchiectomy Rad Tum Ingun Appr                                  $503.41
54535         Orchiectomy Rad Tum W/Abdl Expl                                  $700.65
54550         Expl Undescended Tstis Ingun/Scrotal Area                       $456.54
54555         Exploration For Undescended Testis (Inguinal Or Scrotal Area    $859.10
54560         Expl Undescended Tstis W/Abdl Expl                              $646.29
54565         Exploration For Undescended Testis With Abdominal Exploratio   $1,064.80
54600         Rdctj Torsion Tstis +-Fixj Clat Tstis                            $415.16
54620         Fixj Clat Tstis Spx                                              $287.83
54640         Orchiopexy Ingun Appr +-Hrna Rpr                                $420.03
54641         Orchiopexy, Any Type, With Or Without Hernia Repair            $1,270.50
54645         Orchiopexy, Any Type, With Or Without Hernia Repair Second S    $357.13
54650         Orchiopexy Abdl Appr Intra-Abdl Tstis                           $668.22
54660         Insj Tsticular Prosth Spx                                        $318.89
54661         Insertion Of Testicular Prosthesis (Separate Procedure)         $423.50
54670         Sutr/Rpr Tsticular Inj                                           $390.72
54680         Trnsplj Tstis Thi                                                $747.25
54690         Laps Orchiectomy                                                 $641.67

                                            Page 89
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
54692         Laps Orchiopexy F/Intra-Abdl Tstis                              $721.90
54699         Unlis Laps Px Tstis                                                $0.00
54700         I&D Epididymis Tstis&/Scrotal Space                             $210.30
54800         Bx Epididymis Ndl                                               $128.60
54820         Exploration Of Epididymis, With Or Without Biopsy               $317.37
54830         Exc Local Les Epididymis                                        $329.66
54840         Exc Sprmatocele +-Epididymectomy                                $312.54
54860         Epididymectomy Uni                                              $377.38
54861         Epididymectomy Bi                                               $517.51
54900         Epididymovasostomy Anast Epididymis Uni                         $772.02
54901         Epididymovasostomy Anast Epididymis Bi                         $1,034.72
55000         Pnxr Aspir Hydrocele Tunica Vagis +-Njx Med                     $135.32
55040         Exc Hydrocele Uni                                               $324.94
55041         Exc Hydrocele Bi                                                $460.56
55060         Rpr Tunica Vagis Hydrocele Bottle Typ                           $338.34
55100         Drg Scrotal Wall Absc                                           $224.52
55110         Scrotal Expl                                                    $346.07
55120         Rmvl Fb Scrotum                                                 $416.29
55150         Rescj Scrotum                                                   $437.00
55170         Scrotoplasty                                                       $0.00
55175         Scrotoplasty Smpl                                               $323.29
55180         Scrotoplasty Comp                                               $634.29
55200         Vasotomy Cannulization +-Inc Vas Uni/Bi Spx                     $372.08
55250         Vasect Uni/Bi Spx W/Po Semen Xm                                 $464.21
55300         Vasotomy Vasograms Uni/Bi                                       $188.28
55400         Vasovasostomy Vasovasorrhaphy                                   $493.31
55401         Vasovasostomy, Vasovasorrhaphy                                  $968.00
55450         Lig Prq Vas Deferens Uni/Bi Spx                                 $428.54
55500         Exc Hydrocele Sprmatic Cord Uni Spx                             $344.53
55520         Exc Les Sprmatic Cord Spx                                       $373.31
55530         Exc Varicocele/Lig Sprmatic Veins Spx                           $340.56
55535         Exc Varicocele/Lig Sprmatic Veins Abdl                          $391.30
55540         Exc Varicocele/Lig Veins W/Hrna Rpr                             $463.18
55550         Laps Lig Sprmatic Veins Varicocele                              $389.36
55559         Unlis Laps Sprmatic Cord                                           $0.00
55600         Vesiculotomy                                                    $380.35
55601         Vesiculotomy                                                    $568.70
55605         Vesiculotomy Comp                                               $482.50
55650         Vesiculectomy Any Appr                                          $670.60
55651         Vesiculectomy, Any Approach                                    $1,391.50
55680         Exc Mullerian Dux Cst                                           $319.11
55700         Prostate Needle Biopsy, Any Approach                            $221.62
55705         Bx Prst8 Incal Any Appr                                         $267.59
55720         Prostatotomy Xtrnl Drg Absc Smpl                                $450.69
55725         Prostatotomy Xtrnl Drg Absc Comp                                $517.65
55740         Prostatolithotomy, Removal Of Prostatic Calculus (Separate P    $956.68
55801         Prst8Ect Prnl Stot                                              $985.88
55810         Prst8Ect Prnl Rad                                              $1,226.35
55812         Prst8Ect Prnl Rad Lymph Node Bx                                $1,515.47
55815         Prst8Ect Prnl Rad Bi Pel Lmphadec                              $1,666.53
55821         Prst8Ect Suprapubic Stot 1/2 Stgs                               $804.01
55831         Prst8Ect Retropubic Stot                                        $875.67
55840         Prst8Ect Retropubic Rad +-Nrv Sparing                          $1,257.93
55842         Prst8Ect Retropubic Rad Lymph Node Bx                          $1,347.17
55845         Prst8Ect Retropubic Rad W/Bi Pel Lmphadec                      $1,554.02

                                             Page 90
                         MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
55859         Transperineal Placement Of Needles Or Catheters Into Prostat    $718.75
55860         Expos Prst8 Any Appr Insj Radact Sbst                           $814.23
55862         Expos Prst8 Insj Radact Node Bx                                $1,031.94
55865         Expos Prst8 Insj Radact Bi Pel Lmphadec                        $1,262.46
55866         Laps Prst8Ect Retropubic Rad W/Nrv Sparing                     $1,644.29
55870         Electroejaculation                                              $159.48
55873         Cryosurg Abltj Prst8                                           $1,105.27
55899         Unlis Male Gen Sys                                                 $0.00
55970         Intersex Surg Male Female                                          $0.00
55980         Intersex Surg Female Male                                          $0.00
56000         Incision And Drainage Of Perineal Abscess (Nonobstetrical)        $82.11
56100         Biopsy Of Perineum (Separate Procedure)                           $63.13
56200         Perineoplasty, Repair Of Perineum, Nonobstetrical (Separate     $258.40
56300         Laparoscopy (Peritoneoscopy), Diagnostic;                       $343.84
56301         Laparoscopy, Surgical; With Fulguration Of Oviducts (With Or    $371.69
56302         Laparoscopy, Surgical; With Occlusion Of Oviducts By Device     $410.33
56303         Laparoscopy, Surgical; With Fulguration Or Excision Of Lesio    $642.72
56304         Laparoscopy, Surgical; With Lysis Of Adhesions (Salpingolysi    $626.94
56305         Laparoscopy, Surgical; With Biopsy (Single Or Multiple)         $366.31
56306         Laparoscopy, Surgical; With Aspiration (Single Or Multiple)     $380.44
56307         Laparoscopy, Surgical; With Removal Of Adnexal Structures (P    $671.41
56308         Laparoscopy, Surgical; With Vaginal Hysterectomy W/Wo Remova    $868.21
56309         Laparoscopy, Surgical; With Removal Of Leiomyomata (Single O    $772.52
56310         Laparoscopy, Surgical; Enterolysis (Freeing Of Intestinal Ad    $869.01
56311         Laparoscopy, Surgical; With Retroperitoneal Lymph Node Sampl    $581.38
56312         Laparoscopy, Surgical; With Bilateral Total Pelvic Lymphaden    $745.56
56313         Laparoscopy, Surgical; With Bilateral Total Pelvic Lymphaden    $903.06
56314         Laparoscopy, Surgical; With Drainage Of Lymphocele To Perito    $590.74
56315         Laparoscopy, Surgical; Appendectomy                             $524.68
56316         Laparoscopy, Surgical; Repair Of Initial Inguinal Hernia        $401.88
56317         Laparoscopy, Surgical; Repair Of Recurrent Inguinal Hernia      $515.78
56318         Laparoscopy, Surgical; Orchiectomy                              $682.09
56320         Laparoscopy, Surgical; With Ligation Of Spermatic Veins For     $401.54
56321         Laparoscopy, Surgical; With Adrenalectomy, Partial/Complete,       $0.00
56322         Laparoscopy, Surgical; Transection Of Vagus Nerves, Truncal     $595.41
56323         Laparoscopy, Surgical; Transection Of Vagus Nerves, Selectiv    $710.38
56324         Laparoscopy, Surgical; Cholecystoenterostomy                    $802.47
56340         Laparoscopy, Surgical; Cholecystectomy (Any Method)             $703.64
56341         Laparoscopy, Surgical; Cholecystectomy With Cholangiography     $752.25
56342         Laparoscopy, Surgical; Cholecystectomy With Exploration Of C    $874.20
56343         Laparoscopy, Surgical; With Salpingostomy (Salpingoneostomy)    $770.45
56344         Laparoscopy, Surgical; With Fimbrioplasty                       $724.38
56345         Laparoscopy, Surgical; Splenectomy                                 $0.00
56346         Laparoscopy, Surgical; Gastrostomy, Temporary (Tube Or Rubbe    $511.49
56347         Laparoscopy, Surgical; Jejunostomy (Eg, For Decompression Or       $0.00
56348         Laparoscopy, Surgical; Intestinal Resection, With Anastomosi   $1,332.20
56349         Laparoscopy, Surgical; Esophagogastric Fundoplasty (Eg, Niss   $1,090.82
56350         Hysteroscopy, Diagnostic                                        $215.82
56351         Hysteroscopy, Surgical; With Sampling (Biopsy) Of Endometriu    $260.65
56352         Hysteroscopy, Surgical; With Lysis Of Intrauterine Adhesions    $361.22
56353         Hysteroscopy, Surgical; With Division Or Resection Of Intrau    $399.75
56354         Hysteroscopy, Surgical; With Removal Of Leiomyomata             $555.73
56355         Hysteroscopy, Surgical; With Removal Of Impacted Foreign Bod    $271.56
56356         Hysteroscopy, Surgical; With Endometrial Ablation (Any Metho    $372.59
56360         Peritoneoscopy; Without Biopsy                                  $343.84

                                           Page 91
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
56361         Peritoneoscopy; With Biopsy                                     $366.31
56362         Laparoscopy With Guided Transhepatic Cholangiography; Withou    $286.34
56363         Laparoscopy With Guided Transhepatic Cholangiography; With B    $323.81
56399         Unlisted Procedure, Laparoscopy, Hysteroscopy                      $0.00
56400         Incision And Drainage Of Vulva                                    $83.83
56405         I&D Vulva/Prnl Absc                                             $109.25
56420         I&D Of Bartholin's Gland Absc                                    $142.03
56440         Marsupialization Bartholin's Gland Cyst                         $182.32
56441         Lss Labial Ads                                                  $148.93
56501         Dstrj Les Vulva Smpl                                            $129.82
56515         Dstrj Les Vulva X10Sv                                           $205.12
56600         Biopsy Of Vulva (Separate Procedure)                              $52.09
56605         Bx Vulva/Pr Spx 1 Les                                             $86.16
56606         Bx Vulva/Pr Spx Ea Sep Addl Les                                   $41.28
56620         Vulvectomy Smpl Prtl                                            $492.72
56625         Vulvectomy Smpl Compl                                           $551.19
56630         Vulvectomy Rad Prtl                                             $775.13
56631         Vulvectomy Rad Prtl Uni Inguinofem Lmphadec                    $1,011.48
56632         Vulvectomy Rad Prtl Bi Inguinofem Lmphadec                     $1,207.45
56633         Vulvectomy Rad Compl                                           $1,013.28
56634         Vulvectomy Rad Compl Uni Inguinofem Lmphadec                   $1,104.16
56635         Vulvectomy, Radical; With Inguinofemoral Lymphadenectomy       $1,438.65
56636         Vulvectomy, Radical                                            $1,996.50
56637         Vulvectomy Rad Compl Bi Inguinofem Lmphadec                    $1,336.29
56640         Vulvectomy Rad Compl Iliac&Pel Lmphadec                        $1,332.13
56641         Vulvectomy, Radical, With Inguinofemoral, Iliac,               $2,420.00
56680         Clitoridectomy; Simple                                             $0.00
56685         Clitoridectomy; Extensive                                          $0.00
56700         Prtl Hymenectomy/Revj Hymenal Ring                              $169.07
56710         Plastic Revision Of Hymen                                          $0.00
56720         Hymenotomy, Simple Incision                                       $42.89
56740         Exc Bartholin's Gland Or Cyst                                   $278.77
56800         Plstc Rpr Introitus                                              $243.15
56805         Clitoroplasty F/Intersex State                                 $1,136.94
56810         Prineoplasty Rpr Pr Nonobal Spx                                 $257.76
56820         Colposcopy Vulva                                                $109.82
56821         Colposcopy Vulva W/Bx                                           $148.05
57000         Colpotomy W/Expl                                                $187.90
57010         Colpotomy W/Drg Pel Absc                                        $393.44
57020         Colpocnts Spx                                                     $98.02
57022         I&D Vag Hmtma Obal/Postpartum                                   $162.16
57023         I&D Vag Hmtma Non-Obal                                          $283.36
57050         Cryosurgery Of Vagina                                              $0.00
57057         Laser Surgery Of Vagina                                           $72.60
57060         Electrocautery Of Vagina                                          $27.14
57061         Dstrj Vag Les Smpl                                              $113.80
57063         Chemical Cautery Of Vagina                                         $0.00
57065         Dstrj Vag Les X10Sv                                             $194.05
57100         Bx Vag Mucosa Smpl Spx                                            $89.86
57105         Bx Vag Mucosa X10Sv Req Sutr                                    $142.12
57106         Vagnc Prtl Rmvl Vag Wall                                        $418.95
57107         Vagnc Prtl Rmvl Vag Wall Paravag Tiss                          $1,347.69
57108         Colpectomy, Obliteration Of Vagina; Partial                     $448.54
57109         Vagnc Prtl Rmvl Vag Wall W/Bi Tot Pel Lmphadec                 $1,517.57
57110         Vagnc Compl Rmvl Vag Wall                                       $869.74

                                           Page 92
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
57111         Vagnc Compl Rmvl Vag Wall Paravag Tiss                         $1,601.26
57112         Vagnc Compl Rmvl Vag Wall Tot Pel Lmphadec Bx                  $1,633.86
57120         Colpocleisis Le Fort Typ                                        $482.36
57130         Exc Vag Septum                                                  $181.36
57135         Exc Vag Cst/Tum                                                 $195.20
57150         Irrg Vag&/Appl Medicament Disease                                 $63.92
57155         Insj Uterine Tandems&/Vag Ovoids                                $414.90
57160         Fitg&Insj Pessary/Oth Intravag Support Dev                        $77.51
57170         Dphrm/Crv Cap Fitg W/Instructions                                 $92.86
57180         Intro Any Hemostatic Agt/Pack Vag Hemrrg Spx                    $146.33
57200         Colporrhaphy Sutr Inj Vag                                       $271.72
57210         Colpoprineorrhaphy Sutr Inj Vag&/Pr                             $342.69
57220         Plstc Urtl Sphnctr Vag Appr                                     $295.24
57230         Plstc Rpr Urethrocele                                           $359.51
57240         Ant Colporrhaphy Rpr Cstocele +-Rpr Urethrocele                 $392.53
57250         Post Colporrhaphy Rpr Rectocele +-Prineorrhaphy                 $363.65
57260         Cmbn Anteropost Colporrhaphy                                    $526.57
57265         Cmbn Anteropost Colporrhaphy W/Ntrcl Rpr                        $699.70
57267         Insj Mesh/Prosth Pel Floor Dfct Ea Sit                          $284.41
57268         Rpr Ntrcl Vag Appr Spx                                          $438.32
57270         Rpr Ntrcl Abdl Appr Spx                                         $738.11
57280         Colpopexy Abdl Appr                                             $901.47
57282         Colpopexy Vag Xtr-Prtl Appr                                     $567.03
57283         Colpopexy Vag Intra-Prtl Appr                                   $672.75
57284         Paravag Dfct Rpr                                                $792.64
57287         Rmvl/Revj Sling F/Strs Incont                                   $636.93
57288         Sling Opration F/Strs Incont                                    $744.98
57289         Preyra Px W/Ant Colporrhaphy                                    $700.07
57291         Constj Artif Vag W/O Grf                                         $515.83
57292         Constj Artif Vag W/Grf                                          $806.37
57295         Revj Rmvl Prostc Vag Grf Vag Appr                               $486.12
57300         Clsr Rectovag Fstl Vag/Transanal Appr                           $474.97
57305         Clsr Rectovag Fstl Abdl Appr                                    $808.56
57307         Clsr Rectovag Fstl Abdl Appr W/Concomitant Clst                 $930.35
57308         Clsr Rectovag Fstl Tprnl Prnl Bdy Rcnstj                        $603.59
57310         Clsr Urethrovag Fstl                                            $417.16
57311         Clsr Urethrovag Fstl W/Bulbocavernosus Trnspl                   $475.45
57320         Clsr Vesicovag Fstl Vag Appr                                    $489.77
57330         Clsr Vesicovag Fstl Transvesical&Vag Appr                       $713.76
57335         Vaginoplasty F/Intersex State                                  $1,111.90
57400         Dilat Vag Anes                                                  $137.01
57410         Pel Xm Anes                                                     $146.02
57415         Rmvl Impacted Vag Fb Spx Anes                                   $142.60
57420         Colposcopy Entire Vag W/Cervix If Present                       $115.02
57421         Colposcopy Entire Vag W/Cervix Bx                               $156.94
57425         Laps Surg Colpopexy Ssp Vag Apex                                $902.42
57450         Culdoscopy, Diagnostic;                                         $180.09
57451         Culdoscopy, Diagnostic; With Biopsy And/Or Lysis Of Adhesion    $231.84
57452         Colposcopy Cervix Upr/Adj Vag                                   $112.01
57454         Colposcopy Cervix Bx Cervix&Endocrv Curtg                       $157.78
57455         Colposcopy Cervix Vag Bx Cervix                                 $144.72
57456         Colposcopy Cervix Vag Endocrv Curtg                             $136.93
57460         Colposcopy Cervix Vag Loop Eltrd Bx Cervix                      $339.69
57461         Colposcopy Cervix Vag Eltrd Conization Cervix                   $371.96
57500         Bx 1/Mlt/Local Exc Les +-Fulg Spx                               $138.23

                                            Page 93
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
57505         Endocrv Curtg X Done As Part Dilat&Curtg                        $101.94
57510         Caut Cervix Electro/Thermal                                     $137.22
57511         Caut Cervix Cryocaut 1St/Repeat                                 $147.08
57513         Caut Cervix Laser Abltj                                         $148.59
57520         Conization Cervix +-D&C Rpr Knife/Laser                         $348.61
57522         Conization Cervix +-D&C Rpr Eltrd Exc                           $300.61
57530         Trachelectomy Cervicectomy Amp Cervix Spx                       $327.33
57531         Rad Trachelectomy W/Bi Pel Lmphadec                            $1,647.93
57540         Exc Crv Stump Abdl Appr                                         $743.89
57545         Exc Crv Stump Abdl Appr W/Pel Floor Rpr                         $794.31
57550         Exc Crv Stump Vag Appr                                          $373.91
57555         Exc Crv Stump Vag Appr W/Ant&/Post Rpr                          $565.04
57556         Exc Crv Stump Vag Appr W/Rpr Ntrcl                              $529.41
57700         Cerclage Uterine Cervix Nonobal                                 $261.65
57720         Trachelorrhaphy Plstc Rpr Uterine Cervix Vag                    $288.80
57800         Dilat Crv Canal Instrumental Spx                                  $60.57
57820         Dilation And Curettage Of Cervical Stump                        $125.31
58100         Endometrial Bx +-Endocrv Bx W/O Dilat Spx                       $108.95
58101         Endometrial Washings (Eg, For Cytology Sampling)                  $54.45
58102         Office Endometrial Curettage                                      $92.11
58103         Menstrual Extraction                                            $326.70
58110         Endometrial Bx Conjunct W/Colposcopy                              $53.50
58120         D&C Dx&/Ther                                                    $222.72
58140         Myomectomy 1-4 250 Gm Abdl                                      $876.37
58145         Myomectomy 1-4 250 Gm/< Vag                                     $515.63
58146         Myomectomy 5+ > 250 Gm Abdl                                    $1,100.89
58150         Tah +-Rmvl Tube +-Rmvl Ovary                                    $919.79
58152         Tah +-Rmvl Tube Ovary Colpo-Urtcstopexy                        $1,203.65
58180         Supracrv Abdl Hyst +-Rmvl Tube Ovary                            $919.34
58200         Tah W/Prtl Vagnc Pel Lymph Node Sampling                       $1,277.39
58210         Rad Abdl Hyst W/Bi Pel Lmphadec                                $1,703.11
58240         Pel Exntj Gynecologic Mal                                      $2,262.57
58260         Vag Hyst 250 Gm/<                                               $789.51
58262         Vag Hyst 250 Gm/< W/Rmvl Tube&/Ovary                            $890.54
58263         Vag Hyst 250 Gm/< W/Rmvl Tube Ovary W/Rpr Ntrcl                 $963.47
58267         Vag Hyst 250 Gm/< W/Colpo-Urtcstopexy                          $1,016.64
58270         Vag Hyst 250 Gm/< W/Rpr Ntrcl                                   $858.10
58275         Vag Hyst W/Tot/Prtl Vagnc                                       $946.59
58280         Vag Hyst W/Tot/Prtl Vagnc W/Rpr Ntrcl                          $1,012.04
58285         Vag Hyst Rad Schauta                                           $1,288.28
58290         Vag Hyst F/Uter >250 Gm                                        $1,094.25
58291         Vag Hyst >250 Gm Rmvl Tube&/Ovary                              $1,205.86
58292         Vag Hyst >250 Gm Rmvl Tube&/Ovary W/Rpr Ntrcl                  $1,279.16
58293         Vag Hyst >250 Gm Colpo-Urtcstopexy +-Ndsc Ctrl                 $1,332.34
58294         Vag Hyst >250 Gm Rpr Ntrcl                                     $1,176.71
58300         Insj Intrauterine Dev                                             $94.45
58301         Rmvl Intrauterine Dev                                           $102.50
58310         Artificial Insemination;                                          $65.99
58311         Artificial Insemination; With Sperm Washing And Capacitation      $75.86
58320         Insufflation Of Uterus And Tubes With Air And Co2                 $54.45
58321         Artif Insemination Intra-Crv                                      $81.23
58322         Artif Insemination Intra-Uterine                                  $90.55
58323         Sprm Washg Artif Insemination                                     $18.17
58340         Cathj&Intro Saline Nfs Shg/Hsg                                  $258.94
58345         Transcrv Intro Flp Tube Cath +-Hsg                              $280.22

                                             Page 94
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                         Amount
58346         Insj Heyman Capsls Clinical Brachytx               $426.50
58350         Chromotubation Ovidux Matrls                         $97.37
58353         Endometrial Abltj Thermal W/O Hysteroscopic Gid    $225.72
58356         Endometrial Cryoabltj Us Curtg                     $529.58
58400         Uterine Ssp Spx                                    $412.58
58410         Uterine Ssp Presac Sympth                          $764.50
58500         Hysterosalpingostomy                              $1,101.10
58520         Hysterorrhaphy Rpr Rptd                            $723.35
58540         Hysteroplasty Rpr Uterine Anomal                   $863.43
58545         Laps Myomectomy Exc 1-4 250 Gm/<                   $878.15
58546         Laps Myomectomy Exc 5+ >250 Grams                 $1,107.43
58550         Laps W/Vag Hyst 250 Gm/<                           $866.82
58551         Laparoscopy, Remove Myoma                          $838.44
58552         Laps W/Vag Hyst 250 Gm/< Rmvl Tube&/Ovary          $960.32
58553         Laps W/Vag Hyst >250 Grams                        $1,096.07
58554         Laps Vag Hyst >250 Gm Rmvl Tube&/Ovary            $1,262.49
58555         Hystsc Dx Spx                                      $217.70
58558         Hystsc Bx Endometrium&/Polypc +-D&C                $276.21
58559         Hystsc Lss Intrauterine Ads                        $356.19
58560         Hystsc Div/Rescj Intrauterine Septum               $404.44
58561         Hystsc Rmvl Leiomyomata                            $575.70
58562         Hystsc Rmvl Impacted Fb                            $300.49
58563         Hystsc Endometrial Abltj                           $356.56
58565         Hystsc Occlusion Plmt Prm                         $2,164.28
58578         Unlis Laps Uter                                       $0.00
58579         Unlis Hystsc Uter                                     $0.00
58600         Lig/Trnsxj Flp Tube Abdl/Vag Appr Uni/Bi           $350.54
58605         Lig/Trnsxj Flp Tube Abdl/Vag Postpartum Spx        $317.62
58611         Lig/Trnsxj Flp Tube Done Tm C Dlvr/Surg              $78.21
58615         Occlusion Flp Tube Dev Vag/Suprapubic Appr         $264.10
58660         Laps Lss Ads Spx                                   $669.35
58661         Laps Rmvl Adnexal Struxs                           $654.47
58662         Laps Fulg/Exc Ovary Viscera/Prtl Surf              $709.04
58670         Laps Fulg Oviduxs                                  $355.35
58671         Laps Occlusion Oviduxs Dev                         $356.89
58672         Laps Fimbrioplasty                                 $767.48
58673         Laps Salpingostomy                                 $823.15
58679         Unlis Laps Px Ovidux Ovary                            $0.00
58700         Salpingectomy Compl/Prtl Uni/Bi Spx                $699.97
58720         Salpingo-Oophorectomy Compl/Prtl Uni/Bi Spx        $691.32
58740         Lss Ads                                            $812.33
58750         Tubotubal Anast                                    $898.40
58752         Tubouterine Impltj                                 $882.66
58760         Fimbrioplasty                                      $801.91
58770         Salpingostomy                                      $844.24
58800         Drg Ovarian Cst Uni/Bi Spx Vag                     $335.66
58805         Drg Ovarian Cst Uni/Bi Spx Abdl                    $376.48
58820         Drg Ovarian Absc Vag Opn                           $293.40
58822         Drg Ovarian Absc Abdl                              $614.00
58823         Drg Pel Absc Trvg/Transrct Prq                     $175.68
58825         Trpos Ovary                                        $652.26
58900         Bx Ovary Uni/Bi Spx                                $382.77
58920         Wedge Rescj/Bisctj Ovary Uni/Bi                    $662.00
58925         Ovarian Cstc Uni/Bi                                $687.67
58940         Oophorectomy Prtl/Tot Uni/Bi                       $458.44

                                            Page 95
                         MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
58943         Oophorectomy Prtl/Tot Uni/Bi Ovarian Mal                       $1,097.69
58950         Rescj Prim Prtl Mal W/Bso&Omntc                                $1,017.49
58951         Rescj Prim Prtl Mal W/Bso&Omntc Tah&Lmphadec                   $1,327.58
58952         Rescj Prim Prtl Mal W/Bso&Omntc Rad Debulking                  $1,491.19
58953         Bso W/Omntc Tah&Rad Dsj Debulking                              $1,888.41
58954         Bso W/Omntc Tah Debulking W/Lmphadec                           $2,055.39
58956         Bso Tot Omntc Tah Mal                                          $1,333.61
58960         Lapt Stg/Restg Ovarian Tubal/Prim Mal 2Nd Look                  $890.33
58970         Follicle Pnxr Oocyte Retrieval Any Meth                         $233.64
58972         Culture And Fertilization Of Oocyte(S)                             $0.00
58974         Embryo Tr Intrauterine                                             $0.00
58976         Gamete Zygote/Embryo Intraflp Tr Any Meth                       $258.16
58980         Laparoscopy, Diagnostic (Separate Procedure)                    $356.73
58982         Laparoscopy, Surgical; With Fulguration Of Oviducts (With Or    $627.00
58983         Laparoscopy, Surgical; With Occlusion Of Oviducts By Device     $627.00
58984         Laparoscopy, Surgical; With Fulguration Or Excision Of Lesio    $412.27
58985         Laparoscopy, Surgical; With Lysis Of Adhesions                  $409.17
58986         Laparoscopy, Surgical; With Biopsy (Single Or Multiple)         $380.88
58987         Laparoscopy, Surgical; With Aspiration (Single Or Multiple)     $393.99
58988         Laparoscopy, Surgical; With Removal Of Adnexal Structures (P    $381.91
58990         Hysteroscopy; Diagnostic                                        $175.26
58992         Hysteroscopy; With Lysis Of Intrauterine Adhesions Or Resect    $217.69
58994         Hysteroscopy; With Removal Of Submucous Leiomyomata (Any Met    $264.61
58995         Hysteroscopy                                                       $0.00
58996         Hysteroscopy; With Endometrial Ablation (Any Method)            $234.94
58999         Unlis Px Female Gen Sys                                            $0.00
59000         Amniocnts Dx                                                    $121.48
59001         Amniocnts Ther Amniotic Flu Rdctj Us Gid                        $165.70
59010         Amnioscopy                                                        $72.60
59011         Amnioscopy (Intraovular)                                           $0.00
59012         Cordocnts Intrauterine                                          $231.21
59015         Chornc Villus Sampling                                          $150.50
59020         Ftl Contrcj Strs Tst                                              $68.22
59020   26    Ftl Contrcj Strs Tst                                              $43.19
59020   TC    Ftl Contrcj Strs Tst                                              $25.03
59025         Ftl Non-Strs Tst                                                  $43.71
59025   26    Ftl Non-Strs Tst                                                  $33.56
59025   TC    Ftl Non-Strs Tst                                                  $10.15
59030         Ftl Scalp Bld Sampling                                          $133.67
59031         Fetal Scalp Blood Sampling                                         $0.00
59050         Ftl Mntr Labor Phys Wrttn Reprt S&I                               $58.79
59051         Ftl Mntr Labor Phys Wrttn Reprt Interpj Only                      $50.34
59070         Tabdl Amnionfs Us Gid                                           $394.01
59072         Ftl Umbilical Cord Occlusion W/Us Gid                           $477.63
59074         Ftl Flu Drg Us Gid                                              $375.38
59076         Ftl Shunt Plmt Us Gid                                           $477.63
59100         Hystot Abdl                                                     $777.64
59101         Hysterotomy, Abdominal, For Removal Of Hydatidiform Mole        $348.00
59105         Hysterotomy, Abdominal, For Legal Abortion                     $1,004.30
59106         Hysterotomy, Abdominal, For Legal Abortion                     $1,004.30
59120         Tx Ectopic Pregnancy Req So                                     $775.26
59121         Tx Ectopic Pregnancy W/O So                                     $679.49
59125         Surgical Treatment Of Ectopic Pregnancy                            $0.00
59126         Surgical Treatment Of Ectopic Pregnancy                            $0.00
59130         Tx Ectopic Pregnancy Abdl Pregnancy                             $911.39

                                          Page 96
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
59135         Tx Ectopic Pregnancy Ntrstl Req Tot Hyst                      $932.07
59136         Tx Ectopic Pregnancy Ntrstl Prtl Rescj Uter                   $855.72
59140         Tx Ectopic Pregnancy Crv W/Evac                               $386.53
59150         Laps Tx Ectopic Pregnancy W/O So                              $696.01
59151         Laps Tx Ectopic Pregnancy W/So                                $727.73
59160         Curtg Postpartum                                              $251.44
59200         Insj Crv Dilator Spx                                            $56.63
59300         Episiotomy/Vag Rpr Oth/Thn Attending Phys                     $134.30
59305         Episiotomy Or Vaginal Repair Only, By Other Than Attending    $726.00
59320         Cerclage Cervix Pregnancy Vag                                 $184.59
59325         Cerclage Cervix Pregnancy Abdl                                $273.43
59350         Hysterorrhaphy Rptd Uter                                      $317.23
59351         Hysterorrhaphy Of Ruptured Uterus                            $1,452.00
59400         Ob Care Antepartum Vag Dlvr&Postpartum                       $1,636.80
59409         Vag Dlvr Only                                                 $994.91
59410         Vag Dlvr Only Postpartum Care                                $1,085.54
59412         Xtrnl Cephalic Version +-Tocolss                              $126.79
59414         Dlvr Placenta Spx                                             $121.36
59420         Antepartum Care Only (Separate Procedure)                     $133.10
59425         Antepartum Care Only 4-6 Vsts                                 $392.72
59426         Antepartum Care Only 7+ Vsts                                  $674.37
59430         Postpartum Care Only Spx                                        $98.34
59510         Ob Antepartum Care C Dlvr&Postpartum                         $1,854.08
59514         C Dlvr Only                                                  $1,165.32
59515         C Dlvr Only W/Postpartum Care                                $1,259.90
59525         Stot/Tot Hyst After C Dlvr                                     $523.75
59540         Cesarean Section, Extraperitoneal, Including In-Hospital         $0.00
59541         Cesarean Section, Extraperitoneal, Including In-Hospital         $0.00
59560         Cesarean Section With Hysterectomy, Subtotal, Including      $1,331.00
59561         Cesarean Section With Hysterectomy, Subtotal, Including      $1,512.50
59580         Cesarean Section With Hysterectomy, Total, Including         $1,331.00
59581         Cesarean Section With Hysterectomy, Total, Including         $1,512.50
59610         Ob Antepartum Vag Dlvr&Postpartum After C Dlvr               $1,703.99
59612         Vag Dlvr After C Dlvr                                        $1,053.27
59614         Vag Dlvr After C Dlvr Postpartum Care                        $1,143.90
59618         Antepartum C Dlvr&Postpartum Fa V Ap C Dlver                 $1,946.22
59620         C Dlvr Only Fa V Ap C Dlver                                  $1,223.68
59622         C Dlvr Only Fa V Ap C Dlver W/Postpartum Care                $1,318.26
59800         Treatment Of Spontaneous Abortion, First Trimester            $447.70
59801         Treatment Of Spontaneous Abortion, First Trimester            $326.70
59810         Treatment Of Spontaneous Abortion, Second Trimester           $326.70
59811         Treatment Of Spontaneous Abortion, Second Trimester           $326.70
59812         Tx Incompl Ab Any Tri Compld Surgly                           $277.06
59820         Tx Missed Ab Compld Surgly 1St Tri                            $322.19
59821         Tx Missed Ab Compld Surgly 2Nd Tri                            $299.31
59830         Tx Septic Ab Compld Surgly                                    $432.94
59840         Induced Ab Dilat&Curtg                                        $279.22
59841         Induced Ab Dilat&Evac                                         $367.38
59850         Induced Ab 1+ Iam Njxs Dlvr Fetus                             $389.26
59851         Induced Ab 1+ Iam Njxs Dlvr Fetus D&C&Evac                    $401.21
59852         Induced Ab 1+ Iam Njxs Dlvr Fetus Hystot                      $556.03
59855         Induced Ab 1+ Vag Supp Dlvr Fetus                             $413.18
59856         Induced Ab 1+ Vag Supp Dlvr Fetus D&C&/Evac                   $499.70
59857         Induced Ab 1+ Vag Supp Dlvr Fetus Hystot                      $613.95
59866         Multiftl Pregnancy Rdctj                                      $257.65

                                             Page 97
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
59870         Uterine Evac&Curtg Hydatidiform Mole                            $311.90
59871         Rmvl Cerclage Sutr Under Anes                                   $159.43
59897         Unlis Ftl Invasive W/Us Gid                                        $0.00
59898         Unlis Laps Maternity Care&Dlvr                                     $0.00
59899         Unlis Maternity Care&Dlvr                                          $0.00
60000         I&D Thyroglossal Dux Cst Infct                                  $151.51
60001         Aspir&/Njx Thyr Cst                                               $93.47
60100         Bx Thyr Prq Core Ndl                                            $112.54
60200         Exc Cst/Adenoma Thyr/Trnsxj Isthmus                             $621.51
60210         Prtl Thyr Lobec Uni +-Isthmusectomy                             $666.20
60212         Prtl Thyr Lobec Uni W/Clat Stot Lobec                           $957.40
60220         Tot Thyr Lobec Uni +-Isthmusectomy                              $721.24
60225         Tot Thyr Lobec Uni W/Clat Stot Lobec                            $869.07
60240         Trdec Tot/Compl                                                 $955.55
60245         Thyroidectomy, Subtotal Or Partial;                             $897.03
60246         Thyroidectomy, Subtotal Or Partial; With Removal Of Substern   $1,123.43
60252         Trdec Tot/Stot F/Mal W/Lmtd Nck Dsj                            $1,222.83
60254         Trdec Tot/Stot F/Mal W/Rad Nck Dsj                             $1,627.39
60260         Trdec Rmvl Remaining Tiss Flwg Rmvl Prtn                       $1,042.70
60261         Thyroidectomy, Secondary                                       $1,391.50
60270         Trdec W/Substernal Thyr Sternal Splt/Tthrc                     $1,232.47
60271         Trdec W/Substernal Thyr Crv Appr                               $1,014.22
60280         Exc Thyroglossal Dux Cst/Sinus                                  $417.15
60281         Exc Thyroglossal Dux Cst/Sinus Recrt                            $569.81
60500         Paratrdec/Expl Parathyr                                         $959.16
60502         Paratrdec/Expl Parathyr Re-Expl                                $1,203.31
60505         Paratrdec/Expl Parathyr Medstnl Sternal/Tthrc                  $1,312.32
60510         Transplantation Of Parathyroid Gland(S) During Thyroidectomy       $0.00
60512         Parathyr Autotrnsplj                                            $246.87
60520         Thymectomy Prtl/Tot Transcrv Appr Spx                          $1,022.87
60521         Thymectomy Prtl/Tot W/O Rad Medstnl Dsj Spx                    $1,169.85
60522         Thymectomy Prtl/Tot Rad Medstnl Dsj Spx                        $1,414.24
60540         Adrnlectomy Expl Adrnl Tabdl Lmbr/Dorsal Spx                    $983.68
60545         Adrnlectomy Expl Adrnl Spx Exc Adj Tum                         $1,141.42
60550         Adrenalectomy, Partial Or Complete, Or Exploration Of Adrena   $1,936.00
60555         Adrenalectomy, Partial Or Complete, Or Exploration Of Adrena   $2,178.00
60600         Exc Crtd Bdy Tum W/O Exc Crtd Art                              $1,158.34
60605         Exc Crtd Bdy Tum W/Exc Crtd Art                                $1,333.55
60650         Laps Adrnlectomy Prtl/Compl Tabdl                              $1,134.66
60659         Unlis Laps Endoc Sys                                               $0.00
60699         Unlis Endoc Sys                                                    $0.00
61000         Sdrl Tap Thru Fontanelle/Sutr Inft Uni/Bi 1St                   $100.56
61001         Sdrl Tap Thru Fontanelle/Sutr Inft Uni/Bi Sbsq                  $101.67
61020         Ventr Pnxr Previous Burr Hole W/O Njx                           $118.29
61026         Ventr Pnxr Previous Burr Hole W/Njx                             $124.76
61050         Cisternal/Lat Crv C1-C2 Pnxr W/O Njx Spx                        $108.90
61055         Cisternal/Lat Crv C1-C2 Pnxr W/Njx                              $136.77
61070         Pnxr Shunt Tubing/Rsvr Aspir/Njx                                  $75.32
61105         Tdh Sdrl/Ventr Pnxr                                             $387.47
61106         Twist Drill Hole For Subdural Or Ventricular Puncture; Follo    $382.64
61107         Tdh Sdrl/Ventr Pnxr Implting Ventr Cath/Dev                     $357.60
61108         Tdh Sdrl/Ventr Pnxr Evac&/Drg Sdrl Hmtma                        $740.56
61120         Burr Hole Ventr Pnxr                                            $634.52
61130         Burr Hole(S) For Ventricular Puncture; Followed By Other Sur    $432.20
61140         Burr Hole/Trephine W/Bx Brn/Icra Les                           $1,109.44

                                             Page 98
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                   Amount
61150         Burr Hole/Trephine W/Drg Brn Absc/Cst                       $1,207.99
61151         Burr Hole/Trephine W/Sbsq Tapping Icra Absc/Cst              $869.69
61154         Burr Hole W/Evac&/Drg Hmtma Xdrl/Sdrl                       $1,055.61
61155         Burr Hole(S) With Evacuation And/Or Drainage Of Hematoma,   $1,694.00
61156         Burr Hole W/Aspir Hmtma/Cst Icere                           $1,136.32
61210         Burr Hole Implting Ventr Cath Rsvr Eltrd/Dev Spx             $410.13
61215         Insj Subq Rsvr Pmp/Nfs Sys Ventr Cath                        $377.43
61250         Burr Hole/Trephine Sttl Expl N/Flwd Oth Surg                 $738.48
61251         Burr Hole(S) Or Trephine, Supratentorial, Exploratory,      $1,331.00
61253         Burr Hole/Trephine Ittl Uni/Bi                               $854.48
61304         Crnec/Crx Expl Sttl                                         $1,501.58
61305         Crnec/Crx Expl Ittl                                         $1,810.92
61310         Craniectomy Or Craniotomy, Evacuation Of Hematoma,          $1,936.00
61311         Craniectomy Or Craniotomy, Evacuation Of Hematoma,          $1,936.00
61312         Crnec/Crx F/Evac Hmtma Sttl Xdrl/Sdrl                       $1,711.55
61313         Crnec/Crx F/Evac Hmtma Sttl Icere                           $1,720.25
61314         Crnec/Crx F/Evac Hmtma Ittl Xdrl/Sdrl                       $1,576.98
61315         Crnec/Crx F/Evac Hmtma Ittl Intracerebellar                 $1,894.75
61316         Inc&Subq Plmt Crnl B1 Grf                                      $93.88
61320         Crnec/Crx Drg Icra Absc Sttl                                $1,750.70
61321         Crnec/Crx Drg Icra Absc Ittl                                $1,915.95
61322         Crnec/Crx Dcmprive W/O Lobec                                $1,872.62
61323         Crnec/Crx Dcmprive W/Lobec                                  $1,935.19
61330         Dcmprn Orbit Only Transcrnl                                 $1,500.08
61331         Decompression Of Orbit Only, Transcranial                       $0.00
61332         Expl Orbit Transcrnl Bx                                     $1,792.81
61333         Expl Orbit Transcrnl Rmvl Les                               $1,723.81
61334         Expl Orbit Transcrnl W/Rmvl Fb                              $1,219.90
61340         Stpl Crnl Dcmprn                                            $1,282.59
61341         Other Cranial Decompression (Eg, Subtemporal),              $1,633.50
61343         Crnec Sopl Crv Lam Dcmprn Medulla&Spi Cord                  $2,022.71
61345         Oth Crnl Dcmprn Post Fossa                                  $1,835.79
61440         Crx Sctj Tentorium Cerebelli Spx                            $1,787.74
61450         Crnec Stpl Sctj Compression/Dcmprn Ganglion                 $1,742.11
61458         Crnec Sopl Expl/Dcmprn Crnl Nrv                             $1,845.61
61460         Crnec Sopl Sctj 1+ Crnl Nrv                                 $1,912.58
61470         Crnec Sopl Medullary Trcotomy                               $1,707.77
61480         Crnec Sopl Mesencephal Trcotomy/Pedunculotomy               $1,819.59
61490         Crx Lobotomy W/Cingulotomy                                  $1,745.77
61491         Craniotomy For Lobotomy, Including Cingulotomy              $2,057.00
61500         Crnec Exc Tum/Oth B1 Les Skl                                $1,224.11
61501         Crnec Osteomyelitis                                         $1,020.12
61510         Crnec Treph B1 Flap Crx Exc Tum Sttl                        $1,956.02
61512         Crnec Treph B1 Flap Crx Exc Meningioma Sttl                 $2,380.27
61514         Crnec Treph B1 Flap Crx Exc Brn Absc Sttl                   $1,722.64
61516         Crnec Treph B1 Flap Crx Exc Cst Sttl                        $1,683.21
61517         Impltj Brn Intrcv Chemotx Agt                                  $76.41
61518         Crnec Exc Tum Ittl/Pfos Crblopnt/Midline                    $2,534.87
61519         Crnec Exc Tum Ittl/Pfos Meningioma                          $2,773.95
61520         Crnec Exc Tum Ittl/Pfos Crblopnt Angl Tum                   $3,652.57
61521         Crnec Exc Tum Ittl/Pfos Midline Tum Base Skl                $2,980.83
61522         Crnec Ittl/Pfos Exc Absc                                    $1,960.30
61524         Crnec Ittl/Pfos Exc/Fenestration Cst                        $1,859.30
61526         Crnec Exc Crblopnt Angl Tum                                 $3,356.16
61530         Crnec Exc Crblopnt Angl Tum Middle/Pfos                     $2,857.63

                                           Page 99
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
61531         Sdrl Impltj Strip Eltrds Seizure Mntr                          $1,019.94
61532         Craniectomy, Trephination, Bone Flap Craniotomy;               $3,412.20
61533         Crx B1 Flap Impltj Eltrd Ra Seizure Mntr                       $1,344.42
61534         Crx B1 Flap Exc Epileptogenic Foc W/O Ecog                     $1,429.41
61535         Crx B1 Flap Rmvl Eltrd Ra W/O Exc Cere Tiss Spx                 $818.22
61536         Crx B1 Flap Exc Cere Foc W/Ecog                                $2,377.95
61537         Crx B1 Flap Temporal Lobe W/O Ecog                             $1,723.73
61538         Crx B1 Flap Lobec Temporal Lobe W/Ecog                         $1,825.27
61539         Crx B1 Flap Lobec Oth/Thn Temporal Lobe W/Ecog                 $2,172.50
61540         Crx B1 Flap Lobec Oth/Thn Temporal Lobe W/O Ecog               $2,081.70
61541         Crx B1 Flap Trnsxj Corpus Callosum                             $1,940.00
61542         Crx B1 Flap Tot Hemisphercomy                                  $2,129.00
61543         Crx B1 Flap Prtl/Stot Hemisphercomy                            $1,990.50
61544         Crx B1 Flap Exc/Coagj Choroid Plexus                           $1,699.11
61545         Crx B1 Flap Exc Craniopharyngioma                              $2,957.07
61546         Crx Hypphsec/Exc Pituitary Tum Icra                            $2,106.25
61548         Hypphsec/Exc Pituitary Tum Transnsl/Septal                     $1,450.24
61550         Crnec Craniosynostosis 1 Crnl Sutr                              $857.98
61552         Crnec Craniosynostosis Mlt Crnl Sutrs                          $1,108.29
61553         Craniectomy For Craniostenosis Each Stage Of Multiple Stages       $0.00
61555         Reconstruction Of Skull By Multiple Bone Flaps                     $0.00
61556         Crx Craniosynostosis Frnt/Parietal B1 Flap                     $1,422.43
61557         Crx Craniosynostosis Bifrnt B1 Flap                            $1,563.56
61558         X10Sv Crnec Mlt Sutr Craniosynostosis X W/B1 Grf               $1,602.15
61559         X10Sv Crnec Mlt Sutr Craniosynostosis B1 Agrft                 $2,267.04
61561         Reconstruction Of Skull By Orbital Advancement, Including Su   $1,101.10
61562         Reconstruction Of Skull By Orbital Advancement,                $1,633.50
61563         Exc B9 Tum Crnl B1 W/O Optic Nrv Dcmprn                        $1,779.01
61564         Exc B9 Tum Crnl B1 W/Optic Nrv Dcmprn                          $2,279.61
61566         Crx B1 Flap Slctv Amygdalohippocampectomy                      $2,055.83
61567         Crx B1 Flap Mlt Subpial Trnsxjs W/Ecog                         $2,344.72
61570         Crnec/Crx Exc Fb From Brn                                      $1,653.01
61571         Crnec/Crx Tx Pentrg Wnd Brn                                    $1,796.05
61575         Transoral Sb Bx Dcmprn/Exc Les                                 $2,248.09
61576         Transoral Sb Bx Dcmprn/Exc Les Spltting Tongue                 $3,267.94
61580         Cranfcl Acf Xdrl W/O Orb Exntj                                 $2,197.23
61581         Cranfcl Acf Xdrl Orb Exntj                                     $2,296.93
61582         Cranfcl Acf Xdrl Elvtn Lobe                                    $2,475.10
61583         Cranfcl Acf Idrl Elvtn/Rescj Lobe                              $2,604.03
61584         Oc Acf Xdrl W/O Orb Exntj                                      $2,503.93
61585         Oc Acf Xdrl W/Orb Exntj                                        $2,709.58
61586         Bicoronal Transzygmtc&/Left W/O B1 Grf                         $1,924.77
61590         Itprl Pre-Aur Mcf&Msb                                          $2,819.74
61591         Itprl Post-Aur Mcf                                             $2,971.20
61592         Oc Zygmtc Mcf                                                  $2,819.90
61595         Transtemporal Pcf Jug Foramen/Msb                              $2,074.32
61596         Transcochlear Pcf Jug Foramen/Msb                              $2,435.17
61597         Transcondylar Pcf Jug Foramen/Msb                              $2,583.18
61598         Transpetrosal Pcf Clivus/Foramen Magnum                        $2,324.10
61600         Rescj/Exc Les Base Acf Xdrl                                    $1,842.64
61601         Rescj/Exc Les Base Acf Idrl W/Rpr                              $2,050.27
61605         Rescj/Exc Les Itprl Fossa Space Apex Xdrl                      $2,026.12
61606         Rescj/Exc Les Itprl Fossa Space Apex Idrl W/Rpr                $2,703.00
61607         Rescj/Exc Les Parasellar Sinus Clivus/Msb Xdrl                 $2,503.55
61608         Rescj/Exc Les Parasellar Sinus Clivus/Msb Idrl                 $2,951.34

                                            Page 100
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
61609         Trnsxj/Lig Crtd Art Sinus W/O Rpr                                $648.47
61610         Trnsxj/Lig Crtd Art Sinus W/Rpr Anast/Grf                      $1,760.92
61611         Trnsxj/Lig Crtd Art Petrous Canal W/O Rpr                       $493.00
61612         Trnsxj/Lig Crtd Art Petrous Canal Rpr Anast/Grf                $1,701.51
61613         Obltrj Crtd Arysm Arven Crtd-Fstl Dsj                          $2,893.40
61615         Rescj/Exc Les Base Pcf Vrt Bodies Xdrl                         $2,256.75
61616         Rescj/Exc Les Base Pcf Foramen Vrt Bodies Idrl                 $3,010.86
61618         Sec Rpr Dura Csf Leak Fr Tiss Grf                              $1,160.28
61619         Sec Rpr Dura Csf Leak Local/Regionalized Flap                  $1,389.32
61623         Evasc Temp Balo Artl Occlusion                                  $550.39
61624         Tcat Prm Occlusion/Embolization Prq Cns                        $1,060.85
61626         Tcat Prm Occlusion/Embolization Prq Non-Cns                     $863.20
61680         Surg Icra Arven Malfrmj Sttl Smpl                              $2,080.80
61682         Surg Icra Arven Malfrmj Sttl Cplx                              $4,100.61
61684         Surg Icra Arven Malfrmj Ittl Smpl                              $2,677.39
61686         Surg Icra Arven Malfrmj Ittl Cplx                              $4,325.74
61690         Surg Icra Arven Malfrmj Dural Smpl                             $1,976.97
61692         Surg Icra Arven Malfrmj Dural Cplx                             $3,441.27
61697         Surg Cplx Icra Arysm Icra Appr Crtd Crcj                       $3,416.37
61698         Cplx Icra Icra Vertebrobasilar Crcj                            $3,273.93
61700         Smpl Icra Icra Appr Crtd Crcj                                  $3,402.96
61702         Smpl Icra Icra Vertebrobasilar Crcj                            $3,238.39
61703         Icra Crv Appl Occluding Clamp Crv Crtd Art                     $1,213.16
61705         Arysm Vasc Malfrmj/Crtd-Occlusion Crtd Art                     $2,383.18
61708         Arysm Vasc Malfrmj/Icra Electrothrombosis                      $1,978.22
61710         Arysm Vasc Malfrmj Ia Embolization                             $1,723.95
61711         Anast Artl Xtrc-Icra Arts                                      $2,443.89
61712         Microdissection, Intracranial Or Spinal Procedure               $291.38
61720         Crtj Les Strtctc Burr Globus Pallidus/Thalamus                 $1,163.43
61735         Crtj Les Strtctc Burr Subcortical Strux Oth/Thn                $1,412.21
61750         Strtctc Bx Aspir/Exc Burr Icra Les                             $1,249.97
61751         Strtctc Bx Aspir/Exc Burr Icra Les W/Ct&/Mrg                   $1,228.74
61760         Strtctc Impltj Eltrd Cerebrum Seizure Mntr                     $1,376.09
61770         Strtctc Loclzj Insj Cath/Prb Plmt Radj Src                     $1,449.55
61780         Stereotactic Localization, Any Method, Including Burr Hole(S    $563.73
61790         Crtj Les Strtctc Prq Nulyt Gasserian                             $711.54
61791         Crtj Les Strtctc Prq Nulyt Trigeminal Trc                      $1,020.48
61793         Strtctc Radiosurg 1+ Sess                                      $1,185.73
61795         Strtctc Cptr Asstd Icra Xtrc/Spi                                 $264.85
61850         Tdh/Burr Impltj Nstim Eltrd Cortical                            $852.88
61855         Twist Drill Or Burr Hole(S) For Implantation Of Neurostimula    $894.89
61860         Crnec/Crx Impltj Nstim Eltrd Cere Cortical                     $1,419.25
61863         Strtctc Impltj Nstim Eltrd W/O Mer 1St Ra                      $1,239.54
61864         Strtctc Impltj Nstim Eltrd W/O Mer Ea Ra                         $297.25
61865         Craniectomy Or Craniotomy For Implantation Of Neurostimulato   $1,501.77
61867         Strtctc Impltj Nstim Eltrd W/Mer 1St Ra                        $1,867.52
61868         Strtctc Impltj Nstim Eltrdw/Mer Ea Ra                            $491.74
61870         Crnec Impltj Nstim Eltrd Cerebellar Cortical                    $999.09
61875         Crnec Impltj Nstim Eltrd Cerebellar Subcortical                 $994.79
61880         Revj/Rmvl Icra Nstim Eltrds                                     $466.75
61885         Insj/Rplcmt Crnl Npgr 1 Eltrd Ra                                $472.14
61886         Insj/Rplcmt Crnl Npgr 2+ Eltrd Ra                               $611.15
61888         Revj/Rmvl Crnl Npgr                                             $381.48
62000         Elvtn Deprs Skl Fx Smpl Xdrl                                    $712.49
62005         Elvtn Deprs Skl Fx Compound/Commind Xdrl                       $1,039.80

                                            Page 101
                           MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
62010         Elvtn Deprs Skl Fx W/Rpr Dura&/Dbrdmt Brn                      $1,366.20
62100         Crx Rpr Dural/Csf Leak Rhinorrhea/Otorrhea                     $1,490.48
62115         Rdctj Craniomegalic Skl X W/B1 Grfs/Crnop                      $1,456.69
62116         Rdctj Craniomegalic Skl W/Smpl Crnop                           $1,607.42
62117         Rdctj Craniomegalic Req Crx&Rcnstj +-B1 Grf                    $1,828.57
62120         Rpr Encephalocele Skl Vault W/Crnop                            $1,544.19
62121         Crx F/Rpr Encephalocele Sb                                     $1,391.48
62140         Crnop F/Skl Dfct Up 5 Cm Diam                                   $936.75
62141         Crnop F/Skl Dfct >5 Cm Diam                                    $1,028.25
62142         Rmvl B1 Flap/Prostc Plate Skl                                   $761.80
62143         Rplcmt B1 Flap/Prostc Plate Skl                                 $906.90
62145         Crnop F/Skl Dfct W/Reparative Brn Surg                         $1,288.63
62146         Crnop W/Agrft Up 5 Cm Diam                                     $1,099.08
62147         Crnop W/Agrft >5 Cm Diam                                       $1,315.20
62148         Inc&Retrieval Subq Crnl B1 Grf F/Crnop                          $125.78
62160         Nundsc Icra Plmt/Rplcmt Ventr Cath Shunt Sys                    $179.28
62161         Nundsc Icra Dsj Ads Fenestration Septum Csts                   $1,276.23
62162         Nundsc Icra Fenestration/Exc Cst Plmt Cath Drg                 $1,651.40
62163         Nundsc Icra W/Retrieval Fb                                     $1,046.15
62164         Nundsc Icra Exc Tum Plmt Cath Drg                              $1,779.60
62165         Nundsc Icra Exc Pituitary Tum                                  $1,382.34
62180         Ventriculocisternostomy                                        $1,447.85
62190         Crtj Shunt Sarach/Sdrl-Atr-Jug-Aur                              $779.24
62192         Crtj Shunt Sarach/Sdrl-Prtl-Pleural Oth                         $857.22
62194         Rplcmt/Irrg Sarach/Sdrl Cath                                    $313.73
62200         Ventriculocisternostomy 3Rd Vntrc                              $1,262.07
62201         Ventriculocisternostomy 3Rd Vntrc Neurondsc                    $1,024.34
62220         Crtj Shunt Ventriculo-Atr-Jug-Aur                               $901.63
62223         Crtj Shunt Ventriculo-Prtl-Pleural Oth                          $908.71
62225         Rplcmt/Irrigation Ventr Cath                                    $405.02
62230         Rplcmt/Revj Csf Shunt Valve/Cath Shunt Sys                      $733.47
62252         Reprgrmg Prgrbl Cerebsp Shunt                                     $90.22
62252   26    Reprgrmg Prgrbl Cerebsp Shunt                                     $48.27
62252   TC    Reprgrmg Prgrbl Cerebsp Shunt                                     $41.95
62256         Rmvl Compl Cerebsp Flu Shunt Sys W/O Rplcmt                     $484.34
62258         Rmvl Compl Csf Shunt Sys W/Rplcmt                              $1,004.14
62263         Prq Lss Edrl Ads Sln Njx/Mchnl Loclzj 2+ D                      $683.08
62264         Prq Lss Edrl Ads Sln Njx/Mchnl Loclzj 1 D                       $459.39
62268         Prq Aspir Spi Cord Cst/Syrinx                                   $577.19
62269         Bx Spi Cord Prq Ndl                                             $668.71
62270         Spi Pnxr Lmbr Dx                                                $157.51
62272         Spi Pnxr Ther F/Drg Cerebsp Flu                                 $191.30
62273         Njx Edrl Bld/Clot Patch                                         $186.88
62274         Injection Of Diagnostic Or Therapeutic Anesthetic Or Antispa      $96.73
62275         Injection Of Diagnostic Or Therapeutic Anesthetic Or Antispa      $94.25
62276         Injection Of Diagnostic Or Therapeutic Anesthetic Or Antispa    $118.10
62277         Injection Of Diagnostic Or Therapeutic Anesthetic Or Antispa    $115.35
62278         Injection Of Diagnostic Or Therapeutic Anesthetic Or Antispa      $88.95
62279         Injection Of Diagnostic Or Therapeutic Anesthetic Or Antispa      $89.01
62280         Njx/Nfs Nulyt Sbst Sbst Sarach                                  $347.38
62281         Njx/Nfs Nulyt Sbst Edrl Crv/Thrc                                $317.38
62282         Njx/Nfs Nulyt Sbst Edrl Lmbr Sac                                $393.35
62284         Njx Myelograpy&/Ct Spi                                          $240.58
62286         Injctn Prcdr Pneumdencephalogrphy,Lumbar                        $266.20
62287         Aspir/Dcmprn Prq Nucleus Pulposus 1+ Lvls Lmbr                  $535.44

                                             Page 102
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
62288         Injection Of Substance Other Than Anesthetic, Antispasmodic,    $103.26
62289         Injection Of Substance Other Than Anesthetic, Antispasmodic,      $96.53
62290         Njx Diskograpy Ea Lvl Lmbr                                      $370.45
62291         Njx Diskograpy Ea Lvl Crv/Thrc                                  $324.97
62292         Njx Chemonucleolss Diskograpy 1+ Lmbr                           $489.16
62293         Injection Procedure For Chemonucleolysis, Including Diskogra       $0.00
62294         Njx Artl Occlusion Arven Malfrmj Spi                            $688.09
62298         Injection Of Substance Other Than Anesthetic, Contrast, Or N     $129.82
62310         Njx C+-Dx/Ther Sbst Edrl/Sarach Crv/Thrc                        $252.98
62311         Njx C+-Dx/Ther Sbst Edrl/Sarach Lmbr Sac                        $241.27
62318         Njx Nfs/Bolus Dx/Sbst Edrl/Sarach Crv/Thrc                      $283.07
62319         Njx Nfs/Bolus Dx/Sbst Edrl/Sarach Lmbr Sac                      $251.12
62350         Impltj Revj/Rpsg Ithcl/Edrl Cath Pmp W/O Lam                     $433.17
62351         Impltj Revj/Rpsg Ithcl/Edrl Cath W/Lam                          $720.17
62355         Rmvl Previously Implted Ithcl/Edrl Cath                         $343.16
62360         Impltj/Rplcmt Ithcl/Edrl Drug Nfs Subq Rsvr                     $206.96
62361         Impltj/Rplcmt Ithcl/Edrl Nfs Non-Prgrbl Pmp                     $369.19
62362         Impltj/Rplcmt Ithcl/Edrl Drug Nfs Prgrbl Pmp                    $464.75
62365         Rmvl Subq Rsvr/Pmp                                              $361.94
62367         Elec Alys Prgrbl Pmp W/O Reprgrmg                                 $28.91
62367   26    Elec Alys Prgrbl Pmp W/O Reprgrmg                                 $24.30
62367   TC    Elec Alys Prgrbl Pmp W/O Reprgrmg                                  $0.00
62368         Elec Alys Prgrbl Pmp Reprgrmg                                     $44.16
62368   26    Elec Alys Prgrbl Pmp Reprgrmg                                     $37.38
62368   TC    Elec Alys Prgrbl Pmp Reprgrmg                                      $0.00
63001         Lam W/O Facetec Foramot/Dskc 1/2 Vrt Seg Crv                   $1,086.11
63003         Lam W/O Ffd 1/2 Vrt Seg Thrc                                   $1,100.94
63005         Lam W/O Ffd 1/2 Vrt Seg Lmbr                                   $1,047.54
63010         Laminectomy For Exploration/Decompression Of Spinal Cord And   $1,528.00
63011         Lam W/O Ffd 1/2 Vrt Seg Sac                                      $913.01
63012         Lam W/Rmvl Abnormal Facets Lmbr                                $1,075.78
63015         Lam W/O Ffd >2 Vrt Seg Crv                                     $1,343.96
63016         Lam W/O Ffd >2 Vrt Seg Thrc                                    $1,324.13
63017         Lam W/O Ffd >2 Vrt Seg Lmbr                                    $1,115.57
63020         Lamot Prtl Ffd Hrna8 1 Ntrspc Crv                              $1,047.36
63021         Laminotomy (Hemilaminectomy), For Decompression Of Nerve       $2,178.00
63030         Lamot Prtl Ffd Hrna8 1 Ntrspc Lmbr                              $862.33
63031         Laminotomy (Hemilaminectomy), For Decompression Of Nerve       $2,057.00
63035         Lamot Prtl Ffd Hrna8 Ea Ntrspc Crv/Lmbr                          $203.75
63040         Lamot Prtl Ffd Hrna8 Reexpl 1 Ntrspc Crv                       $1,285.96
63041         Laminotomy (Hemilaminectomy), For Herniated                    $2,456.30
63042         Lamot Prtl Ffd Hrna8 Reexpl 1 Ntrspc Lmbr                      $1,216.41
63043         Lamot Prtl Ffd Hrna8 Reexpl 1 Ntrspc Ea Crv                        $0.00
63044         Lamot W/Prtl Ffd Hrna8 Reexpl 1 Ntrspc Ea Lmbr                     $0.00
63045         Lam Facetec&Foramot 1 Sgm Crv                                  $1,149.95
63046         Lam Facetec&Foramot 1 Sgm Thrc                                 $1,102.22
63047         Lam Facetec&Foramot 1 Sgm Lmbr                                 $1,032.63
63048         Lam Facetec&Foramot 1 Sgm Ea Crv Thrc/Lmbr                       $211.19
63050         Lamop Crv W/Dcmprn Spi Cord 2/More Vrt Seg                     $1,416.33
63051         Lamop Crv Dcmprn Spi Cord 2+ Seg Rcnstj B1                     $1,609.81
63055         Transpedicular Dcmprn Spi Cord 1 Sgm Thrc                      $1,500.39
63056         Transpedicular Dcmprn Spi Cord 1 Sgm Lmbr                      $1,380.99
63057         Transpedicular Dcmprn 1 Sgm Ea Thrc/Lmbr                        $332.31
63060         Hemilaminectomy (Laminectomy) For Herniated Intervertebral     $2,178.00
63064         Costovrt Dcmprn Thrc 1 Sgm                                     $1,676.61

                                           Page 103
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
63065         Transthoracic Approach For Herniated Intervertebral Disk Or    $2,359.50
63066         Costovrt Dcmprn Thrc Ea Sgm                                     $213.63
63075         Dskc Ant Dcmprn Crv 1 Ntrspc                                   $1,347.85
63076         Dskc Ant Dcmprn Crv Ea Ntrspc                                   $264.32
63077         Dskc Ant Dcmprn Thrc 1 Ntrspc                                  $1,434.23
63078         Dskc Ant Dcmprn Thrc Ea Ntrspc                                  $206.77
63081         Vcrpec Ant Dcmprn Crv 1 Sgm                                    $1,626.75
63082         Vcrpec Ant Dcmprn Crv Ea Sgm                                    $284.51
63085         Vcrpec Tthrc Dcmprn Thrc 1 Sgm                                 $1,799.29
63086         Vcrpec Tthrc Dcmprn Thrc Ea Sgm                                 $204.39
63087         Vcrpec Thoracolmbr Dcmprn Lwr Thrc/Lmbr 1 Sgm                  $2,324.60
63088         Vcrpec Thoracolmbr Dcmprn Lwr Thrc/Lmbr Ea Sgm                  $278.75
63090         Vcrpec Transprtl/Rpr Dcmprn Thrc Lmbr/Sac 1 Sgm                $1,844.14
63091         Vcrpec Transprtl/Rpr Dcmprn Thrc Lmbr/Sac Ea Sgm                $188.42
63101         Vcrpec Lat Xtrcavitary Dcmprn Thrc 1 Sgm                       $2,130.72
63102         Vcrpec Lat Xtrcavitary Dcmprn Lmbr 1 Sgm                       $2,130.72
63103         Vcrpec Lat Xtrcavitary Dcmprn Thrc/Lmbr Ea Sgm                  $249.57
63170         Lam W/Myelotomy Crv Thrc/Thoracolmbr                           $1,370.54
63172         Lam W/Drg Imed Cst/Syrinx Sarach Space                         $1,224.17
63173         Lam W/Drg Imed Cst/Syrinx Prtl/Pleural Space                   $1,498.81
63180         Lam&Sctj Dentate Ligms Crv 1/2 Seg                             $1,278.40
63182         Lam&Sctj Dentate Ligms Crv >2 Seg                              $1,343.48
63185         Lam W/Rhizotomy 1/2 Seg                                         $964.22
63190         Lam W/Rhizotomy >2 Seg                                         $1,168.12
63191         Lam W/Sctj Spi Accessory Nrv                                   $1,215.51
63192         Laminectomy For Section Of Spinal Accessory Nerve                  $0.00
63194         Lam Cordotomy Sctj 1 Trc 1 Stg Crv                             $1,346.54
63195         Lam Cordotomy Sctj 1 Trc 1 Stg Thrc                            $1,281.65
63196         Lam Cordotomy Sctj Bth Trcs 1 Stg Crv                          $1,556.11
63197         Lam Cordotomy Sctj Bth Trcs 1 Stg Thrc                         $1,456.42
63198         Lam Cordotomy Sctj Bth Trcs 2 Stgs Crv                         $1,521.73
63199         Lam Cordotomy Sctj Bth Trcs 2 Stgs Thrc                        $1,834.94
63200         Lam Rls Tethered Spi Cord Lmbr                                 $1,311.25
63210         Laminectomy, One Or Two Segments, For Excision Of Intraspina   $2,359.50
63215         Laminectomy, One Or Two Segments, For Excision Of Intraspina   $2,359.50
63220         Laminectomy, One Or Two Segments, For Excision Of Intraspina   $2,057.00
63225         Laminectomy, One Or Two Segments, For Excision Of Intraspina   $1,210.00
63240         Laminectomy, More Than Two Segments, For Excision Of           $2,456.30
63241         Laminectomy, More Than Two Segments, For Excision Of           $2,456.30
63242         Laminectomy, More Than Two Segments, For Excision Of           $2,456.30
63250         Lam Exc/Occlusion Avm Spi Cord Crv                             $2,626.69
63251         Lam Exc/Occlusion Avm Spi Cord Thrc                            $2,756.12
63252         Lam Exc/Occlusion Avm Spi Cord Thoracolmbr                     $2,731.61
63265         Lam Exc/Evac Ispi Les Oth/Thn Neo Xdrl Crv                     $1,482.05
63266         Lam Exc/Evac Ispi Les Oth/Thn Neo Xdrl Thrc                    $1,533.61
63267         Lam Exc/Evac Ispi Les Oth/Thn Neo Xdrl Lmbr                    $1,245.79
63268         Lam Exc/Evac Ispi Les Oth/Thn Neo Xdrl Sac                     $1,227.14
63270         Lam Exc Ispi Les Oth/Thn Neo Idrl Crv                          $1,831.63
63271         Lam Exc Ispi Les Oth/Thn Neo Idrl Thrc                         $1,847.46
63272         Lam Exc Ispi Les Oth/Thn Neo Idrl Lmbr                         $1,730.43
63273         Lam Exc Ispi Les Oth/Thn Neo Idrl Sac                          $1,680.37
63275         Lam Bx/Exc Ispi Neo Xdrl Crv                                   $1,617.21
63276         Lam Bx/Exc Ispi Neo Xdrl Thrc                                  $1,602.16
63277         Lam Bx/Exc Ispi Neo Xdrl Lmbr                                  $1,432.32
63278         Lam Bx/Exc Ispi Neo Xdrl Sac                                   $1,416.35

                                           Page 104
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
63280         Lam Bx/Exc Ispi Neo Idrl Xmed Crv                              $1,939.67
63281         Lam Bx/Exc Ispi Neo Idrl Xmed Thrc                             $1,916.48
63282         Lam Bx/Exc Ispi Neo Idrl Xmed Lmbr                             $1,807.14
63283         Lam Bx/Exc Ispi Neo Idrl Sac                                   $1,720.60
63285         Lam Bx/Exc Ispi Neo Idrl Imed Crv                              $2,431.92
63286         Lam Bx/Exc Ispi Neo Idrl Imed Thrc                             $2,404.84
63287         Lam Bx/Exc Ispi Neo Idrl Imed Thoracolmbr                      $2,484.81
63290         Lam Bx/Exc Ispi Neo Xdrl-Idrl Les Any Lvl                      $2,523.49
63295         Ostpl Rcnstj Dorsal Spi Elmnts Flwg Ispi Px                     $320.57
63300         Vcrpec Les 1 Sgm Xdrl Crv                                      $1,669.12
63301         Vcrpec Les 1 Sgm Xdrl Thrc Tthrc                               $1,844.97
63302         Vcrpec Les 1 Sgm Xdrl Thrc Thoracolmbr                         $1,874.35
63303         Vcrpec Les 1 Sgm Xdrl Lmbr/Sac Transprtl/Rpr                   $2,010.36
63304         Vcrpec Les 1 Sgm Idrl Crv                                      $1,995.33
63305         Vcrpec Les 1 Sgm Idrl Thrc Tthrc                               $2,118.06
63306         Vcrpec Les 1 Sgm Idrl Thrc Thoracolmbr                         $1,969.80
63307         Vcrpec Les 1 Sgm Idrl Lmbr/Sac Transprtl/Rpr                   $2,000.87
63308         Vcrpec Les 1 Sgm Ea Sgm                                         $340.97
63600         Crtj Les Spi Cord Strtctc Prq                                   $781.20
63610         Strtctc Stimj Spi Cord Prq Spx N/Flwd Oth Surg                  $430.73
63615         Strtctc Bx Aspir/Exc Les Spi Cord                              $1,090.72
63650         Prq Impltj Nstim Eltrd Ra Edrl                                  $392.47
63652         Percutaneous Implantation Of Neurostimulator Electrodes Intr       $0.00
63655         Lam Impltj Nstim Eltrds Plate/Paddle Edrl                       $726.17
63656         Laminectomy For Implantation Of Neurostimulator Electrodes E       $0.00
63657         Laminectomy For Implantation Of Neurostimulator Electrodes;     $607.68
63658         Laminectomy For Implantation Of Neurostimulator Electrodes;    $1,089.39
63660         Revj/Rmvl Spi Nstim Eltrd Prq Ra/Plate/Paddle                   $393.92
63685         Insj/Rplcmt Spi Npgr Dir/Induxive Coupling                      $461.60
63688         Revj/Rmvl Implted Spi Npgr                                      $365.42
63690         Electronic Analysis Of Implanted Neurostimulator Pulse Gener      $40.51
63691         Electronic Analysis Of Implanted Neurostimulator Pulse Gener      $41.02
63700         Rpr Meningocele <5 Cm Diam                                     $1,123.32
63702         Rpr Meningocele >5 Cm Diam                                     $1,151.45
63704         Rpr Myelomeningocele <5 Cm Diam                                $1,448.81
63706         Rpr Myelomeningocele >5 Cm Diam                                $1,627.67
63707         Rpr Dural/Cerebsp Flu Leak X Req Lam                            $796.16
63708         Repair Dural/Csf Leak                                          $1,010.40
63709         Rpr Dural/Csf Leak/Pseudomeningocele W/Lam                      $997.81
63710         Dural Grf Spi                                                   $983.26
63740         Crtj Shunt Lmbr Sarach-Prtl-Pleural/Oth W/Lam                   $798.30
63741         Crtj Shunt Lmbr Sarach-Prtl-Pleural Prq X Lam                   $533.89
63744         Rplcmt Irrigation/Revj Lumbosarach Shunt                        $568.93
63746         Rmvl Entire Lumbosarach Shunt Sys W/O Rplcmt                    $435.04
63750         Insertion, Subarachnoid Catheter With Reservoir And/Or Pump     $909.45
63780         Insertion Or Replacement, Subarachnoid Or Epidural Catheter,    $308.85
64400         Njx Anes Trigeminal Nrv Any Div/Branch                          $117.69
64402         Njx Anes Facial Nrv                                             $113.47
64405         Njx Anes Grter Occipital Nrv                                    $108.86
64408         Njx Anes Vagus Nrv                                              $114.82
64410         Njx Anes Phrenic Nrv                                            $150.94
64412         Njx Anes Spi Accessory Nrv                                      $147.09
64413         Njx Anes Crv Plexus                                             $125.40
64415         Single Nerve Block Injection, Arm Nerve                         $163.03
64416         Njx Anes Brach Plexus Cont Nfs Cath Daily Mgmt                  $160.67

                                            Page 105
                           MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
64417         Njx Anes Ax Nrv                                                $171.08
64418         Njx Anes Suprascapular Nrv                                     $149.31
64420         Njx Anes Intercostal Nrv 1                                     $176.22
64421         Multiple Nerve Block Injections, Rib Nerves                    $264.43
64425         Njx Anes Ilioingun Iliohypogstr Nrv                            $132.71
64430         Njx Anes Pudendal Nrv                                          $154.38
64435         Njx Anes Paracrv Nrv                                           $155.68
64440         Injection, Anesthetic Agent; Paravertebral Nerve (Thoracic,     $77.70
64441         Injection, Anesthetic Agent; Paravertebral Nerves, Multiple    $102.43
64442         Injection, Anesthetic Agent; Paravertebral Facet Joint Nerve    $88.86
64443         Injection, Anesthetic Agent; Paravertebral Facet Joint Nerve    $57.59
64445         Njx Anes Sciatic Nrv 1                                         $157.56
64446         Njx Anes Sciatic Nrv Cont Nfs Daily Mgmt                       $168.51
64447         Njx Anes Fem Nrv 1                                              $78.70
64448         Njx Anes Fem Nrv Cont Nfs Daily Mgmt                           $153.69
64449         Njx Anes Lmbr Plexus Post Cont Nfs Daily Mgmt                  $151.50
64450         Njx Anes Oth Prph Nrv/Branch                                    $97.50
64470         Njx Anes&/Strd Jt Nrv Crv/Thrc 1 Lvl                           $252.24
64472         Njx Anes&/Strd Jt Nrv Crv/Thrc Ea Lvl                          $123.48
64475         Njx Anes&/Strd Jt Nrv Lmbr/Sac 1 Lvl                           $223.64
64476         Injection Of Lower Back Spinal Joint Or Nerve                  $105.90
64479         Njx Anes&/Strd Tfrml Edrl Crv/Thrc 1 Lvl                       $346.50
64480         Njx Anes&/Strd Tfrml Edrl Crv/Thrc Ea Lvl                      $149.98
64483         Njx Anes&/Strd Tfrml Edrl Lmbr/Sac 1 Lvl                       $351.60
64484         Njx Anes&/Strd Tfrml Edrl Lmbr/Sac Ea Lvl                      $155.97
64505         Njx Anes Sphenopalatine Ganglion                                $99.40
64508         Njx Anes Crtd Sinus Spx                                        $152.75
64510         Njx Anes Stellate Ganglion Crv Sympathetic                     $165.66
64517         Njx Anes Suprior Hypogstr Plexus                               $186.03
64520         Njx Anes Lmbr/Thrc Pvrt Sympathetic                            $220.99
64530         Njx Anes Celiac Plexus +-Rad Mntr                              $207.34
64550         Appl Surf Tc Nstim                                              $18.08
64553         Prq Impltj Nstim Eltrds Crnl Nrv                               $193.39
64555         Prq Impltj Nstim Eltrds Prph Nrv                               $202.88
64560         Prq Impltj Nstim Eltrds Autonomic Nrv                          $193.06
64561         Prq Impltj Nstim Eltrds Sac Nrv                                $371.96
64565         Prq Impltj Nstim Eltrds Neuromuscular                          $192.11
64573         Inc Impltj Nstim Eltrds Crnl Nrv                               $543.48
64575         Inc Impltj Nstim Eltrds Prph Nrv                               $278.95
64577         Inc Impltj Nstim Eltrds Autonomic Nrv                          $317.78
64580         Inc Impltj Nstim Eltrds Neuromuscular                          $293.26
64581         Inc Impltj Nstim Eltrds Sac Nrv                                $719.17
64585         Revj/Rmvl Prph Nstim Eltrds                                    $513.65
64590         Insertion/Rplcmt Peripheral/Gastric Npgr                       $374.25
64595         Revision/Rmvl Peripheral/Gastric Npgr                          $465.94
64600         Dstrj Trigeminal Nrv Supraorb Infraorb Branch                  $450.84
64605         Dstrj Nulyt Trigeminal Nrv 2/3 Div                             $548.81
64610         Dstrj Nulyt Trigeminal Nrv 2/3 Div Rad Mntr                    $610.02
64612         Chemodnrvtj Musc Musc Innervated Facial Nrv                    $173.33
64613         Chemodnrvtj Musc Nck Musc                                      $186.52
64614         Chemodnrvtj Musc Xtr&/Trnk Musc                                $204.93
64620         Dstrj Nulyt Intercostal Nrv                                    $282.56
64622         Dstrj Nulyt Pvrt Facet Jt Nrv Lmbr/Sac 1 Lvl                   $398.81
64623         Dstrj Nulyt Pvrt Facet Jt Nrv Lmbr/Sac Ea Lvl                  $128.18
64626         Dstrj Nulyt Pvrt Facet Jt Nrv Crv/Thrc 1 Lvl                   $377.02

                                              Page 106
                           MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
64627         Dstrj Nulyt Pvrt Facet Jt Nrv Crv/Thrc Ea Lvl                   $142.69
64630         Dstrj Nulyt Pudendal Nrv                                        $219.43
64640         Dstrj Nulyt Oth Prph Nrv/Branch                                 $263.17
64650         Chemodnrvtj Eccrine Glnds Bth Ax                                  $61.67
64653         Chemodnrvtj Eccrine Glnds Oth Area Pr D                           $71.18
64680         Dstrj Nulyt +-Rad Mntr Celiac Plexus                            $323.15
64681         Dstrj Nulyt +-Rad Mntr Suprior Hypogstr Plexus                  $457.55
64702         Neurp Dgtal 1/Bth Sm Dgt                                        $322.29
64704         Neurp Nrv Hand/Foot                                             $318.93
64708         Neurp Major Prph Nrv Arm/Leg Oth/Thn Specified                  $444.79
64712         Neurp Major Prph Nrv Arm/Leg Sciatic Nrv                        $497.66
64713         Neurp Major Prph Nrv Arm/Leg Brach Plexus                       $675.06
64714         Neurp Major Prph Nrv Arm/Leg Lmbr Plexus                        $571.11
64716         Neurp&/Trpos Crnl Nrv                                           $456.20
64718         Neurp&/Trpos Ur Nrv Elbw                                        $480.36
64719         Neurp&/Trpos Ur Nrv Wrst                                        $374.50
64721         Neurp&/Trpos Median Nrv Carpl Tunnel                            $369.45
64722         Dcmprn Unspecified Nrv                                          $302.72
64726         Dcmprn Plntar Dgtal Nrv                                         $284.56
64727         Int Neurolss Req Mcrscp                                         $190.42
64732         Trnsxj/Avlsn Supraorb Nrv                                       $331.03
64734         Trnsxj/Avlsn Infraorb Nrv                                       $372.28
64736         Trnsxj/Avlsn Mental Nrv                                         $353.54
64738         Trnsxj/Avlsn Inf Alveolar Nrv Osteom                            $423.38
64740         Trnsxj/Avlsn Lngl Nrv                                           $389.81
64742         Trnsxj/Avlsn Facial Nrv Diffial/Compl                           $438.73
64744         Trnsxj/Avlsn Grter Occipital Nrv                                $381.69
64746         Trnsxj/Avlsn Phrenic Nrv                                        $423.08
64752         Trnsxj/Avlsn Vagus Nrv Tthrc                                    $461.31
64755         Trnsxj/Avlsn Vagus Nrv Prox Stomach                             $768.44
64760         Trnsxj/Avlsn Vagus Nrv Abdl                                     $413.26
64761         Trnsxj/Avlsn Pudendal Nrv                                       $381.57
64762         Transection Or Avulsion Of                                         $0.00
64763         Trnsxj/Avlsn Obturator Nrv Xtrpel                               $487.57
64764         Transection Or Avulsion Of Obturator Nerve, Extrapelvic, Wit    $617.10
64766         Trnsxj/Avlsn Obturator Nrv Intrapel                             $563.85
64768         Transection Or Avulsion Of Obturator Nerve, Intrapelvic,        $895.40
64771         Trnsxj/Avlsn Oth Crnl Nrv Xdrl                                  $542.53
64772         Trnsxj/Avlsn Oth Spi Nrv Xdrl                                   $507.86
64774         Exc Neuroma Cutan Nrv Surgly Identifiable                       $361.09
64776         Exc Neuroma Dgtal Nrv 1/Bth Sm Dgt                              $355.74
64778         Exc Neuroma Dgtal Nrv Ea Dgt                                    $189.61
64782         Exc Neuroma Hand/Foot Xcp Dgtal Nrv                             $407.84
64783         Exc Neuroma Hand/Foot Ea Nrv Xcp Sm Dgt                         $229.68
64784         Exc Neuroma Major Prph Nrv Xcp Sciatic                          $663.57
64786         Exc Neuroma Sciatic Nrv                                        $1,044.88
64787         Impltj Nrv End In B1/Musc                                       $265.63
64788         Exc Neurofibroma/Neurolemmoma Cutan Nrv                         $324.92
64790         Exc Neurofibroma/Neurolemmoma Major Prph Nrv                    $766.71
64792         Exc Neurofibroma/Neurolemmoma X10Sv                             $971.51
64795         Bx Nrv                                                          $189.98
64802         Sympth Crv                                                      $572.78
64803         Sympathectomy, Cervical                                        $1,210.00
64804         Sympth Cervicothrc                                              $896.69
64806         Sympathectomy, Cervicothoracic                                 $1,936.00

                                             Page 107
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                     Amount
64809         Sympth Thoracolmbr                             $768.66
64811         Sympathectomy, Thoracolumbar                  $1,936.00
64814         Remove Sympathetic Nerves                      $955.90
64818         Sympth Lmbr                                    $631.37
64819         Sympathectomy, Lumbar                         $1,452.00
64820         Sympth Dgtal Arts Ea Dgt                       $703.45
64821         Sympth Rdl Art                                 $643.15
64822         Sympth Ur Art                                  $640.23
64823         Sympth Supfc Plmr Arch                         $742.53
64824         64818/Periarterial Sympathectomy                  $0.00
64830         Microdissection And/Or Microrepair Of Nerve    $193.04
64831         Sutr Dgtal Nrv Hand/Foot 1 Nrv                 $665.29
64832         Sutr Dgtal Nrv Hand/Foot Ea Dgtal Nrv          $352.05
64834         Sutr 1 Nrv Hand/Foot Common Sens Nrv           $698.49
64835         Sutr 1 Nrv Hand/Foot Median Motor Thenar       $754.55
64836         Sutr 1 Nrv Hand/Foot Ur Motor                  $751.78
64837         Sutr Ea Nrv Hand/Foot                          $391.11
64840         Sutr Post Tibl Nrv                             $830.06
64856         Sutr Prph Nrv Arm/Leg Xcp Sciatic W/Trpos      $933.20
64857         Sutr Prph Nrv Arm/Leg Xcp Sciatic W/O Trpos    $977.84
64858         Sutr Sciatic Nrv                              $1,143.47
64859         Sutr Ea Major Prph Nrv                         $263.44
64861         Sutr Brach Plexus                             $1,269.29
64862         Sutr Lmbr Plexus                              $1,282.73
64864         Sutr Facial Nrv Xtrc                           $818.97
64865         Sutr Facial Nrv Itprl +-Grfg                   $995.84
64866         Anast Facial-Spi Accessory                     $993.61
64868         Anast Facial-Hypoglossal                       $916.15
64870         Anast Facial-Phrenic                           $968.70
64872         Sutr Nrv Req Sec/Dlyd Sutr                     $125.91
64874         Sutr Nrv Req X10Sv Moblj/Trpos Nrv             $184.19
64876         Sutr Nrv Req Shrt B1 Xtr                       $191.70
64885         Nrv Grf Head/Nck <4 Cm                        $1,125.86
64886         Nrv Grf Head/Nck >4 Cm                        $1,324.27
64890         Nrv Grf 1 Strand Hand/Foot <4 Cm              $1,015.17
64891         Nrv Grf 1 Strand Hand/Foot >4 Cm               $948.05
64892         Nrv Grf 1 Strand Arm/Leg <4 Cm                 $950.77
64893         Nrv Grf 1 Strand Arm/Leg >4 Cm                $1,029.55
64895         Nrv Grf Mlt Strands Hand/Foot <4 Cm           $1,170.85
64896         Nrv Grf Mlt Strands Hand/Foot > 4 Cm          $1,256.72
64897         Nrv Grf Mlt Strands Arm/Leg <4 Cm             $1,200.78
64898         Nrv Grf Mlt Strands Arm/Leg >4 Cm             $1,291.29
64901         Nrv Grf Ea Nrv 1 Strand                        $622.44
64902         Nrv Grf Ea Nrv Mlt Strands                     $713.81
64905         Nrv Pedcl Tr 1St Stg                           $909.78
64907         Nrv Pedcl Tr 2Nd Stg                          $1,246.30
64999         Unlis Px Nrvs Sys                                 $0.00
65091         Evsc Oc Cnts W/O Implt                         $608.74
65093         Evsc Oc Cnts W/Implt                           $638.42
65101         Encl Eye W/O Implt                             $665.94
65103         Encl Eye Implt Musc X Attached Implt           $693.85
65105         Encl Eye Implt Musc Attached Implt             $753.97
65110         Exntj Orbit Rmvl Orb Cnts Only                $1,086.98
65112         Exntj Orbit Rmvl Orb Cnts W/Ther Rmvl B1      $1,274.44
65114         Exntj Orbit Rmvl Orb Cnts W/Musc/Myoq Flap    $1,323.82

                                           Page 108
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
65125         Modificaj Oc Implt W/Plmt/Rplcmt Pegs Spx                       $460.86
65130         Insj Oc Implt Sec After Evsc Scll Shell                         $654.35
65135         Insj Oc Implt After Encl Musc X Attached                        $668.05
65140         Insj Oc Implt After Encl Musc Attached                          $711.06
65150         Rinsj Oc Implt +-Cjncl Grf                                      $584.80
65155         Rinsj Oc Implt Rnfcmt&/Attachment Musc                          $765.72
65175         Rmvl Oc Implt                                                   $599.10
65205         Rmvl Fb Xtrnl Eye Cjncl Supfc                                     $50.05
65210         Rmvl Fb Xtrnl Eye Embedded Scjncl/Scll Nonprf8                    $60.01
65220         Rmvl Fb Xtrnl Eye Crnl W/O Slit Lamp                              $50.86
65222         Rmvl Fb Xtrnl Eye Crnl W/Slit Lamp                                $64.51
65230         Removal Of Foreign Body, Intraocular From Anterior Chamber,     $810.70
65235         Rmvl Fb Io From Ant Chamber Eye/Lens                            $562.03
65240         Removal Of Foreign Body, Intraocular From Lens (Without Extr    $810.70
65245         Removal Of Foreign Body, Intraocular From Lens (Without Extr    $225.50
65260         Rmvl Fb Io From Post Sgm Mag Xtrj Ant/Post Route                $847.01
65265         Rmvl Fb Io From Post Sgm Nonmag Xtrj                            $956.41
65270         Rpr Lac Cjnc +-Nonprf8 Lac Scl Dir Clsr                         $214.87
65272         Rpr Lac Cjnc Moblj&Reargmt W/O Hospization                      $361.05
65273         Rpr Lac Cjnc Moblj&Reargmt W/Hospization                        $376.55
65275         Rpr Lac Crn Nonprf8 +-Rmvl Fb                                   $419.12
65280         Rpr Lac Crn&/Scl Prf8 X Invg Uveal Tiss                         $598.62
65285         Rpr Lac Crn&/Scl Prf8 W/Repos/Rescj Uveal Tiss                  $958.21
65286         Rpr Lac Appl Tiss Glue Wnd Crn&/Scl                             $522.99
65290         Rpr Wnd Eo Muscle Tendon&/Tenon's Capsule                       $450.50
65300         Delimiting Keratotomy                                           $133.10
65400         Exc Les Crn Xcp Pterygium                                       $552.83
65410         Bx Crn                                                           $120.54
65420         Exc/Trpos Pterygium W/O Grf                                      $438.84
65426         Exc/Trpos Pterygium W/Grf                                       $478.92
65430         Scraping Crn Dx F/Smr&/Culture                                  $238.49
65435         Rmvl Crnl Epithe +-Chemocaut                                      $84.59
65436         Rmvl Crnl Epithe W/Appl Chelating Agt                           $378.24
65450         Dstrj Les Crn Crtx Pc/Thermocaut                                $392.25
65600         Mlt Pnxrs Ant Crn                                               $339.08
65650         Venti Mask                                                         $0.00
65710         Keratoplasty Lamellar                                           $934.62
65730         Keratoplasty Pentrg Xcp Aphk                                    $992.07
65750         Keratoplasty Pentrg Aphk                                       $1,075.70
65755         Keratoplasty Pentrg Pseudophakia                               $1,067.90
65760         Keratomileusis                                                 $2,057.00
65765         Keratophakia                                                   $2,057.00
65767         Epikeratoplasty                                                $2,530.60
65770         Keratoprosth                                                   $1,210.85
65771         Rdl Keratotomy                                                     $0.00
65772         Crnl Relaxing Inc Corrj Induced Astigmatism                     $429.44
65775         Crnl Wedge Rescj Corrj Induced Astigmatism                      $495.19
65780         Oc Surf Rcnstj Amniotic Memb Trnsplj                            $759.17
65781         Oc Surf Rcnstj Limbal Stem Cell Algrft                         $1,158.90
65782         Oc Surf Rcnstj Limbal Cjncl Agrft                               $999.33
65800         Pcnts Eye Spx Dx Aspir Aqueous                                  $158.28
65805         Pcnts Eye Spx Ther Rls Aqueous                                  $158.28
65810         Pcnts Eye Spx Rmvl Vts&/Dscj Memb                               $484.77
65815         Pcnts Eye Spx Rmvl Bld                                          $503.59
65820         Goniotomy                                                       $707.95

                                            Page 109
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
65825         Goniotomy With Goniopuncture                                    $810.70
65830         Goniopuncture, Without Goniotomy                                $810.70
65850         Trabeculotomy Ab Externo                                        $754.50
65855         Trabeculoplasty Laser Surg 1+ Sess                              $341.81
65860         Severing Ads Ant Sgm Laser Tq Spx                               $281.51
65865         Severing Ads Ant Sgm Incal Tq Spx Goniosynechiae                $456.33
65870         Severing Ads Ant Sgm Incal Spx Ant Synechiae                    $506.26
65875         Severing Ads Ant Sgm Incal Spx Post Synechiae                   $527.70
65880         Severing Ads Ant Sgm Incal Spx Corneovitreal                    $558.99
65900         Rmvl Epithelial Downgrowth Ant Chamber Eye                      $850.03
65920         Rmvl Implted Matrl Ant Sgm Eye                                  $647.23
65930         Rmvl Bld Clot Ant Sgm Eye                                       $574.29
66020         Njx Ant Chamber Eye Spx Air/Liq                                 $149.17
66030         Njx Ant Chamber Eye Spx Med                                     $129.81
66130         Exc Les Scl                                                     $574.95
66150         Fstlj Scl Glc Treph Irdec                                       $685.85
66155         Fstlj Scl Glc Thermocaut Irdec                                  $682.88
66160         Fstlj Scl Glc Sclercomy Punch/Scissors Irdec                    $787.81
66165         Fstlj Scl Glc Iridencleisis/Iridotasis                          $667.60
66170         Fstlj Scl Glc Trbec Ab Externo                                  $931.50
66172         Fstlj Scl Glc Trbec Ab Externo Scarring                        $1,141.82
66180         Aqueous Shunt Eo Rsvr                                           $992.72
66185         Revj Aqueous Shunt Eo Rsvr                                      $618.49
66220         Rpr Scll Staphyloma W/O Grf                                     $624.39
66225         Rpr Scll Staphyloma W/Grf                                       $773.73
66250         Revj/Rpr Oprative Wnd Ant Sgm                                   $514.38
66500         Iridotomy Stab Inc Spx Xcp Transfixion                          $331.71
66505         Iridotomy Stab Inc Spx Transfixion                              $356.97
66600         Irdec Crnlsclrl/Crnl Sctj Rmvl Les                              $665.76
66605         Irdec Crnlsclrl/Crnl Sctj Cyclectomy                            $918.08
66625         Irdec Crnlsclrl/Crnl Sctj Prph Glc Spx                          $457.28
66630         Irdec Crnlsclrl/Crnl Sctj Sector Glc Spx                        $512.38
66635         Irdec Crnlsclrl/Crnl Sctj Optical Spx                           $487.25
66680         Rpr Iris Ciliary Bdy                                            $433.47
66682         Sutr Iris Ciliary Bdy Spx Retrieval Sutr                        $514.61
66700         Ciliary Bdy Dstrj Dthrm                                         $382.46
66701         Cyclodiathermy; Subsequent                                      $266.20
66702         Ciliary Body Destruction, Any Method (Eg, Diathermy, Cryothe       $0.00
66710         Ciliary Bdy Dstrj Cyclopc Transscll                             $377.67
66711         Ciliary Bdy Dstrj Cyclopc Ndsc                                  $503.80
66720         Ciliary Bdy Dstrj Crtx                                          $394.87
66721         Cyclocryotherapy; Subsequent                                    $859.10
66740         Ciliary Bdy Dstrj Cyclodial                                     $383.51
66741         Cyclodialysis; Subsequent                                       $411.40
66761         Iridotomy/Irdec Laser Surg 1+ Sess                              $361.99
66762         Iridoplasty Pc 1+ Sess                                          $384.81
66770         Dstrj Cst/Les Iris/Ciliary Bdy                                  $423.72
66800         Discission Of Lens Capsule; Incisional Technique (Needling O    $338.80
66801         Discission Of Lens Capsule; Incisional Technique (Needling O    $169.40
66802         Discission Of Lens Capsule; Laser Surgery (One Or More Stage    $614.30
66820         Dscj Sec Membranous Ctrc Stab Inc                               $411.87
66821         Post-Cataract Laser Surgery                                     $237.96
66825         Rpsg Io Lens Prosth Req Inc Spx                                 $690.87
66830         Rmvl Sec Membranous Ctrc Corneo-Scll Sctj                       $580.20
66840         Rmvl Lens Matrl Aspir Tq 1+ Stgs                                $565.27

                                            Page 110
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
66850         Rmvl Lens Matrl Phacofragmentation Aspir                        $640.27
66852         Rmvl Lens Matrl Pars Plna Appr +-Vtrc                           $690.44
66915         Expression Of Lens, Linear, One Or More Stages                 $1,331.00
66920         Rmvl Lens Matrl Icapsl                                          $618.84
66930         Rmvl Lens Matrl Icapsl F/Dislc Lens                             $712.23
66940         Rmvl Lens Matrl Xcapsl                                          $642.64
66945         Extraction Of Lens With Or Without Iridectomy;                 $1,512.50
66980         Insert Intraocular Lens Prothesis; Cat. Ext.1 Stg              $1,815.00
66982         Xcapsl Ctrc Rmvl Insj Lens Prosth 1 Stg                         $893.22
66983         Icapsl Ctrc Xtrj Insj Io Lens Prosth 1 Stg                      $580.00
66984         Cataract Removal, Insertion Of Lens                             $679.77
66985         Insj Io Lens Prosth X W/Cncrnt Rmvl                             $601.94
66986         Exchng Io Lens                                                  $818.45
66990         Use Oph Endoscope                                                 $84.42
66999         Unlis Ant Sgm Eye                                                  $0.00
67005         Rmvl Vts Ant Appr Prtl Rmvl                                     $383.38
67010         Rmvl Vts Ant Appr Stot Rmvl Vtrc                                $449.59
67015         Aspir/Rls Flu Pars Plna                                         $553.70
67025         Njx Vts Sub Pars Plna/Limbal Spx                                $788.07
67027         Impltj Intravitreal Drug Dlvr Sys Rmvl Vts                      $893.42
67028         Intravitreal Njx Pharmacologic Agt Spx                          $336.73
67030         Dscj Vts Strands Pars Plna                                      $438.37
67031         Severing Vts Strands Laser 1+ Stgs                              $317.07
67035         Vtrctmy Mechncl Pars Plana Apprch W/Wo Rmvl Lens               $2,662.00
67036         Vtrc Mchnl Pars Plna                                            $807.82
67038         Vtrc Mchnl Pars Plna Epirta Memb Stripping                     $1,411.08
67039         Vtrc Mchnl Pars Plna Focal Endolaser Pc                        $1,027.38
67040         Vtrc Mchnl Pars Plna Endolaser Panrta Pc                       $1,187.53
67101         Rpr Rta Dtchmnt 1+ Sess Crtx/Dthrm +-Drg                        $654.70
67105         Rpr Rta Dtchmnt 1+ Sess Pc +-Drg Subrta                         $582.30
67107         Rpr Rta Dtchmnt Scll Buckling +-Implt                          $1,049.96
67108         Rpr Rta Dtchmnt W/Vtrc Any Meth                                $1,438.04
67109         Repair Of Retinal Detachment, One Or More Sessions; By Techn   $1,227.97
67110         Rpr Rta Dtchmnt Njx Air/Oth Gas                                 $906.91
67112         Rpr Rta Dtchmnt Scll Buckling/Vtrc Pt                          $1,193.71
67115         Rls Encircling Matrl                                            $454.20
67120         Rmvl Implted Matrl Post Sgm Eo                                  $683.45
67121         Rmvl Implted Matrl Post Sgm Io                                  $826.28
67141         Proph Rta Dtchmnt W/O Drg 1+ Sess Crtx Dthrm                    $467.92
67145         Proph Rta Dtchmnt W/O Drg 1+ Sess                               $420.63
67208         Dstrj Loclzd Les Retina 1+ Sess Crtx Dthrm                      $479.67
67210         Dstrj Loclzd Les Retina 1+ Sess Pc                              $574.26
67218         Dstrj Les Retina 1+ Sess Radj Impltj                           $1,232.76
67220         Dstrj Les Choroid Pc 1+ Sess                                    $874.04
67221         Dstrj Les Choroid Pdt                                           $328.34
67225         Dstrj Les Choroid Pdt 2Nd Eye 1 Sess                              $27.45
67227         Dstrj Retinopathy 1+ Sess Crtx Dthrm                            $490.89
67228         Dstrj Retinopathy 1+ Sess Pc                                    $894.82
67250         Scll Rnfcmt Spx W/O Grf                                         $719.14
67255         Scll Rnfcmt Spx W/Grf                                           $748.87
67299         Unlis Post Sgm                                                     $0.00
67311         Strabismus Recession/Rescj 1 Hrzntl Musc                        $495.78
67312         Strabismus Recession/Rescj 2 Hrzntl Musc                        $611.28
67313         Strabismus Surgery On Patient Not Previously Operated On, An   $1,004.30
67314         Strabismus Recession/Rescj 1 Ver Musc                           $560.16

                                           Page 111
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                     Amount
67316         Strabismus Recession/Rescj 2/More Ver Musc                     $680.00
67318         Strabismus Any Suprior Oblq Musc                               $586.77
67320         Trpos Any Eo Musc                                              $241.42
67331         Strabismus Previous Eye X Involve Eo Musc                      $229.51
67332         Strabismus Scarring Eo Musc/Rstcv Myopathy                     $250.35
67334         Strabismus Post Fixj Sutr Tq +-Musc Recession                  $222.06
67335         Plmt Adjustable Sutr Strabismus                                $138.75
67340         Strabismus Expl&/Rpr Detached Eo Musc                          $274.49
67343         Rls X10Sv Scar Tiss W/O Detaching Eo Musc Spx                  $556.73
67345         Chemodnrvtj Eo Musc                                            $276.24
67350         Biopsy Of Extraocular Muscle                                   $181.95
67399         Unlis Oc Musc                                                     $0.00
67400         Orbt W/O B1 Flap Expl +-Bx                                      $842.02
67405         Orbt W/O B1 Flap Drg Only                                       $718.17
67412         Orbt W/O B1 Flap Rmvl Les                                       $848.62
67413         Orbt W/O B1 Flap Rmvl Fb                                        $837.47
67414         Orbt W/O B1 Flap Rmvl B1 Dcmprn                                 $950.01
67415         Fine Ndl Aspir Orb Cnts                                          $98.31
67420         Orbt B1 Flap/Window Lat Rmvl Les                              $1,474.38
67430         Orbt B1 Flap/Window Lat Rmvl Fb                               $1,124.87
67440         Orbt B1 Flap/Window Lat Drg                                   $1,081.39
67445         Orbt B1 Flap/Window Lat Rmvl B1 Dcmprn                        $1,141.89
67450         Orbt B1 Flap/Window Lat Expl +-Bx                             $1,109.04
67500         Retrobulbar Njx Med Spx                                          $61.47
67505         Retrobulbar Njx Alcohol                                          $66.25
67510         Retrobulbr Inj;Radgrphy                                          $66.55
67515         Njx Med/Other Sbst Tenon's Capsule                               $53.53
67550         Orb Implt Insj                                                  $852.56
67560         Orb Implt Rmvl/Revj                                            $868.47
67570         Optic Nrv Dcmprn                                              $1,099.86
67599         Unlis Orbit                                                       $0.00
67700         Blepharotomy Drg Absc Eyelid                                   $229.99
67710         Severing Tarsorrhaphy                                          $222.33
67715         Canthotomy Spx                                                 $215.24
67800         Exc Chalazion 1                                                $145.66
67801         Exc Chalazion Mlt Sm Lid                                       $269.26
67805         Exc Chalazion Mlt Diff Lids                                    $287.84
67808         Exc Chalazion Anes Req Hospization 1/Mlt                       $341.03
67810         Bx Eyelid                                                       $191.39
67820         Corrj Trichiasis Epilation Forceps Only                          $75.80
67825         Corrj Trichiasis Epilation Oth/Thn Forceps                     $112.07
67830         Corrj Trichiasis Inc Lid Mrgn                                  $339.87
67835         Corrj Trichiasis Inc Lid Mrgn W/Fr Muc Memb Grf                $400.79
67840         Exc Les Eyelid W/O Clsr/W/Smpl Dir Clsr                        $274.50
67850         Dstrj Les Lid Mrgn <1 Cm                                       $287.64
67875         Temp Clsr Eyelids Sutr                                         $310.69
67880         Constj Ads Median Trph/Ctrph                                   $501.99
67882         Constj Ads Median Trph/Ctrph Trpos Plate                       $601.14
67900         Rpr Brow Ptosis                                                $628.04
67901         Rpr Blpos Frntis Musc Sutr/Oth Matrl                            $509.81
67902         Rpr Blpos Frntis Musc Autol Fscal Sling                        $515.05
67903         Rpr Blpos Levator Rescj/Advmnt Int                             $668.49
67904         Rpr Blpos Levator Rescj/Advmnt Xtrnl                           $702.06
67906         Rpr Blpos Suprior Rectus Fscal Sling                           $606.56
67907         Repair Of Blepharoptosis; Superior Rectus Tendon Transplant   $1,089.00

                                            Page 112
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                      Amount
67908         Rpr Blpos Conjunctivo-Tarso-Musc-Levator Rescj   $523.37
67909         Rdctj >Corrj Ptosis                              $555.25
67911         Corrj Lid Retrcj                                 $428.35
67912         Corrj Lagophthalmos Impltj Upr Eyelid Lid Load   $967.29
67914         Rpr Ectropion Sutr                               $484.36
67915         Rpr Ectropion Thermocaut                         $413.72
67916         Rpr Ectropion Exc Tarsal Wedge                   $639.03
67917         Rpr Ectropion X10Sv                              $591.18
67921         Rpr Entropion Sutr                               $466.15
67922         Rpr Entropion Thermocaut                         $407.78
67923         Rpr Entropion Exc Tarsal Wedge                   $645.43
67924         Rpr Entropion X10Sv                              $559.50
67930         Sutr Recent Wnd Eyelid Prtl Thkns                $450.43
67935         Sutr Recent Wnd Eyelid Full Thkns                $660.93
67938         Rmvl Embedded Fb Eyelid                          $264.67
67950         Canthoplasty                                     $532.84
67961         Exc&Rpr Eyelid One-4Th Lid Mrgn                  $597.16
67966         Exc&Rpr Eyelid > One-4Th Lid Mrgn                $565.39
67971         Rcnstj Eyelid Full Thkns < 2-3Rd 1 Stg           $651.39
67973         Rcnstj Eyelid Full Thkns Tot Lwr 1 Stg           $846.09
67974         Rcnstj Eyelid Full Thkns Tot Upr 1 Stg           $839.61
67975         Rcnstj Eyelid Full Thkns 2Nd Stg                 $613.02
67999         Unlis Eyelids                                      $0.00
68020         Inc Cjnc Drg Cst                                 $261.78
68040         Expression Cjncl Follicles                       $209.37
68100         Bx Cjnc                                          $236.20
68110         Exc Les Cjnc Up 1 Cm                             $290.63
68115         Exc Les Cjnc > 1 Cm                              $296.03
68130         Exc Les Cjnc W/Adj Scl                           $490.30
68135         Dstrj Les Cjnc                                   $266.22
68200         Scjncl Njx                                        $45.40
68320         Cjp Cjncl Grf/X10Sv Reargmt                      $449.85
68325         Cjp Buccal Muc Memb Grf                          $522.42
68326         Cjp Rcnstj Cul-De-Sac Cjncl Grf/Reargmt          $510.56
68328         Cjp Rcnstj Cul-De-Sac Buccal Muc Memb Grf        $581.29
68330         Rpr Symblepharon Cjp W/O Grf                     $453.70
68335         Rpr Symblepharon Fr Grf Cjnc/Buccal Muc Memb     $530.27
68340         Rpr Symblepharon Div                             $558.24
68360         Cjncl Flap Bridge/Prtl Spx                       $412.34
68362         Cjncl Flap Tot                                   $569.83
68371         Hrvg Cjncl Algrft Liv Don                        $359.83
68399         Unlis Cjnc                                         $0.00
68400         Inc Drg Lacrimal Glnd                            $344.24
68420         Inc Drg Lacrimal Sac                             $379.97
68440         Snip Inc Lacrimal Punctum                        $217.16
68500         Exc Lacrimal Glnd Xcp Tum Tot                    $811.02
68505         Exc Lacrimal Glnd Xcp Tum Prtl                   $843.69
68510         Bx Lacrimal Glnd                                 $488.58
68520         Exc Lacrimal Sac                                 $580.40
68525         Bx Lacrimal Sac                                  $247.75
68530         Rmvl Fb/Dacryolith Lacrimal Psages               $489.09
68540         Exc Lacrimal Glnd Tum Frnt Appr                  $774.54
68550         Exc Lacrimal Glnd Tum Invg Osteom                $955.97
68700         Plstc Rpr Canaliculi                             $525.69
68705         Corrj Everted Punctum Caut                       $280.00

                                           Page 113
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
68720         Dacryocstorhinostomy                                            $654.51
68745         Conjunctivorhinostomy W/O Tube                                  $640.73
68750         Conjunctivorhinostomy Insj Tube/Stent                           $658.61
68760         Clsr Lacrimal Punctum Thermocaut Lig/Laser                      $213.55
68761         Clsr Lacrimal Punctum Plug Ea                                   $178.51
68770         Clsr Lacrimal Fstl Spx                                          $741.15
68800         Dilation Of Lacrimal Punctum, With Or Without Irrigation, Un      $63.89
68801         Dilat Lacrimal Punctum +-Irrg                                     $71.46
68810         Probe Nasolacrimal Dux +-Irrg                                   $159.73
68811         Probe Nasolacrimal Dux +-Irrg Anes                              $178.80
68815         Probe Nasolacrimal Dux +-Irrg Insj Tube/Stent                   $424.37
68820         Probing Of Nasolacrimal Duct, With Or Without Irrigation, Un      $84.50
68825         Probing Of Nasolacrimal Duct, With Or Without Irrigation, Un    $128.19
68830         Probing Of Nasolacrimal Duct, With Or Without Irrigation, Un    $171.06
68840         Probe Lacrimal Canaliculi +-Irrg                                $109.00
68850         Njx Cntrst Medium Dacryocstograpy                               $627.44
68899         Unlis Lacrimal Sys                                                 $0.00
69000         Drg Xtrnl Ear Absc/Hmtma Smpl                                   $166.75
69005         Drg Xtrnl Ear Absc/Hmtma Comp                                   $194.60
69020         Drg Xtrnl Aud Canal Absc                                        $203.69
69090         Ear Piercing                                                      $48.40
69100         Bx Xtrnl Ear                                                      $95.82
69105         Bx Xtrnl Aud Canal                                              $118.94
69110         Exc Xtrnl Ear Prtl Smpl Rpr                                     $288.49
69120         Exc Xtrnl Ear Compl Amp                                         $310.50
69140         Exc Exostosis Xtrnl Aud Canal                                   $569.17
69145         Exc Soft Tiss Les Xtrnl Aud Canal                               $237.14
69150         Rad Exc Xtrnl Aud Canal Les W/O Nck Dsj                         $914.70
69155         Rad Exc Xtrnl Aud Canal Les Nck Dsj                            $1,377.95
69200         Rmvl Fb Xtrnl Aud Canal W/O Anes                                $116.27
69205         Rmvl Fb Xtrnl Aud Canal Anes                                      $98.58
69210         Rmvl Impacted Cerumen Spx 1/Bth Ears                              $47.82
69220         Dbrdmt Mstdc Cavity Smpl                                        $118.19
69221         Debridement, Mastoidectomy Cavity, Simple (Eg, Routine            $48.40
69222         Dbrdmt Mstdc Cavity Cplx                                        $195.19
69223         Debridement, Mastoidectomy Cavity, Complex (Eg, With Anesthe      $90.75
69300         Otoplasty Protruding Ear +-Size Rdctj                           $412.72
69301         Otoplasty, Protruding Ear, With Or Without Size Reduction      $1,004.30
69310         Rcnstj Xtrnl Aud Canal Spx                                      $745.61
69320         Rcnstj Xtrnl Aud Canal Cgen Atresia 1 Stg                      $1,130.98
69399         Unlis Xtrnl Ear                                                    $0.00
69400         Eustachian Tube Nfltj Transnsl Cathj                            $118.92
69401         Eustachian Tube Nfltj Transnsl W/O Cathj                          $73.03
69405         Eustachian Tube Cathj Transtympanic                             $234.23
69410         Focal Application Of Phase Control Substance, Middle Ear (Ba      $87.99
69420         Mrgt Aspir&/Eustachian Tube Nfltj                               $167.01
69421         Mrgt Aspir&/Eustachian Tube Nfltj Anes                          $147.42
69424         Ventilating Tube Rmvl Anes                                      $112.73
69425         Ventilating Tube Removal When Originally Inserted By Another      $78.65
69433         Tmpst Local/Topical Anes                                        $174.88
69434         Tympanostomy (Requiring Insertion Of Ventilating Tube), Loca    $307.50
69436         Tmpst Anes                                                      $161.17
69437         Tympanostomy (Requiring Insertion Of Ventilating Tube), Gene    $252.65
69440         Middle Ear Expl Thru Postaur/Ear Canal Inc                      $537.64
69450         Tympanolss Transcanal                                           $410.03

                                           Page 114
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                        Amount
69501         Transmastoid Antrt                                $627.82
69502         Mstdc Compl                                       $841.95
69505         Mstdc Modf Rad                                    $876.71
69511         Mstdc Rad                                         $910.95
69530         Petrous Apicectomy Rad Mstdc                     $1,255.17
69535         Rescj Temporal B1 Xtrnl                          $2,290.98
69540         Exc Aural Polyp                                   $183.66
69550         Exc Aural Glomus Tum Transcanal                   $752.11
69552         Exc Aural Glomus Tum Transmastoid                $1,264.00
69554         Exc Aural Glomus Tum Extnd                       $2,112.65
69601         Revj Mstdc Rsltg Compl Mstdc                      $904.30
69602         Revj Mstdc Rsltg Modf Rad Mstdc                   $915.62
69603         Revj Mstdc Rsltg Rad Mstdc                        $942.97
69604         Revj Mstdc Rsltg Tmpp                             $941.02
69605         Revj Mstdc W/Apicectomy                          $1,220.14
69610         Tympanic Memb Rpr +-Sit Prepj Prf8J Patch         $376.91
69611         Tympanic Membrane Patching With Tissue Graft         $0.00
69620         Myringoplasty                                     $462.92
69631         Tmpp W/O Mstdc 1St/Revj W/O Ocr                    $688.20
69632         Tmpp W/O Mstdc 1St/Revj Ocr                       $873.79
69633         Tmpp W/O Mstdc 1St/Revj Prosth Torp               $834.66
69635         Tmpp Antrt/Mastoidotomy W/O Ocr                   $882.21
69636         Tmpp Antrt/Mastoidotomy Ocr                      $1,027.18
69637         Tmpp Antrt/Mastoidotomy Prosth Torp              $1,020.48
69641         Tmpp Mstdc W/O Ocr                                $863.16
69642         Tmpp Mstdc Ocr                                   $1,127.64
69643         Tmpp Mstdc Ntc/Rcnsted Wall W/O Ocr              $1,031.32
69644         Tmpp Mstdc Ntc/Rcnsted Canal Wall Ocr            $1,131.48
69645         Tmpp Mstdc Rad/Compl W/O Ocr                     $1,095.05
69646         Tmpp Mstdc Rad/Compl Ocr                         $1,193.64
69650         Stapes Moblj                                      $663.90
69660         Stapedectomy/Stapedotomy                          $798.71
69661         Stapedectomy/Stapedotomy W/Footplate Drill Out   $1,045.30
69662         Revj Stapedectomy/Stapedotomy                    $1,022.66
69666         Rpr Oval Window Fstl                              $670.18
69667         Rpr Round Window Fstl                             $671.86
69670         Mastoid Obltrj Spx                                $782.40
69676         Tympanic Neurectomy                               $666.38
69677         Tympanic Neurectomy                                  $0.00
69700         Clsr Postaur Fstl Mastoid Spx                     $548.12
69710         Impltj/Rplcmt Emgnt B1 Cndj Dev Temporal B1          $0.00
69711         Rmvl/Rpr Emgnt B1 Cndj Dev Temporal B1            $713.90
69714         Impltj Oi Implt B1 W/O Mstdc                      $932.77
69715         Impltj Oi Implt B1 Mstdc                         $1,196.70
69717         Rplcmt Oi Implt B1 W/O Mstdc                      $960.20
69718         Rplcmt Oi Implt B1 Mstdc                         $1,203.60
69720         Dcmprn Nrv Itprl Lat Geniculate                   $978.81
69725         Dcmprn Nrv Itprl Medial Geniculate               $1,648.19
69740         Sutr Nrv Itprl +-Grf/Dcmprn Lat Geniculate       $1,028.45
69745         Sutr Nrv Itprl +-Grf/Dcmprn Medial Geniculate    $1,085.38
69799         Unlis Middle Ear                                     $0.00
69801         Labyrinthotomy Transcanal                         $597.21
69802         Labyrinthotomy Mstdc                              $883.33
69805         Endolymphatic Sac W/O Shunt                       $929.49
69806         Endolymphatic Sac Shunt                           $837.55

                                           Page 115
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                               Amount
69820         Fenestration Semicircular Canal                          $703.80
69840         Revj Fenestration Opration                               $666.00
69905         Labyrinthectomy Transcanal                               $754.63
69910         Labyrinthectomy Mstdc                                    $908.36
69915         Vstblr Nrv Sctj Translabyrinthine Appr                  $1,383.95
69930         Cochlear Dev Impltj +-Mstdc                             $1,116.38
69949         Unlis Inner Ear                                             $0.00
69950         Vstblr Nrv Sctj Transcrnl                               $1,684.00
69955         Tot Facial Nrv Dcmprn&/Rpr                              $1,742.49
69960         Dcmprn Int Aud Canal                                    $1,749.59
69965         Eustachian Tuboplasty                                       $0.00
69970         Rmvl Tum Temporal B1                                    $1,903.49
69979         Unlis Temporal B1 Middle Fossa                              $0.00
69990         Microsurg Tqs Req Use Oprating Mcrscp                    $222.59
70002         Pneumoencephalography;Sprv & Interp Only                 $227.50
70003         Pneumoencephalography;Complete Procedure                 $227.50
70010         Myelograpy Post Fossa Rs&I                               $228.95
70010   26    Myelograpy Post Fossa Rs&I                                 $60.83
70010   TC    Myelograpy Post Fossa Rs&I                               $168.12
70011         Myelography, Posterior Fossa; Complete Procedure         $191.10
70011   TC    Myelography, Posterior Fossa; Complete Procedure         $133.77
70015         Cistrng Positive Cntrst Rs&I                             $114.03
70015   26    Cistrng Positive Cntrst Rs&I                               $60.72
70015   TC    Cistrng Positive Cntrst Rs&I                               $53.31
70016         Cisternography, Positive Contrast; Complete Procedure    $191.10
70016   TC    Cisternography, Positive Contrast; Complete Procedure    $133.77
70020         Ventriculogrphy;Air Contrast Suprv & Interp Only         $141.05
70020   26    Ventriculogrphy;Air Contrast Suprv & Interp Only           $42.32
70020   TC    Ventriculogrphy;Air Contrast Suprv & Interp Only           $98.74
70021         Ventrclgraphy;Postive Cntrst Sprv & Intrp Only           $136.50
70022         Stereotactic Localization,Head                           $163.60
70030         Radex Eye Detcj Fb                                         $24.73
70030   26    Radex Eye Detcj Fb                                          $8.86
70030   TC    Radex Eye Detcj Fb                                         $15.87
70040         Radiologic Examination, Eye;                               $76.44
70040   26    Radiologic Examination, Eye;                               $22.93
70040   TC    Radiologic Examination, Eye;                               $53.51
70050         Radiologic Examination, Eye;                               $95.55
70050   26    Radiologic Examination, Eye;                               $28.67
70050   TC    Radiologic Examination, Eye;                               $66.89
70100         Radex Mndbl Prtl < 4 Views                                 $29.12
70100   26    Radex Mndbl Prtl < 4 Views                                  $9.22
70100   TC    Radex Mndbl Prtl < 4 Views                                 $19.90
70110         Radex Mndbl Compl Minimum 4 Views                          $36.93
70110   26    Radex Mndbl Compl Minimum 4 Views                          $12.56
70110   TC    Radex Mndbl Compl Minimum 4 Views                          $24.37
70120         Radex Mastoids < 3 Views Pr Side                           $33.59
70120   26    Radex Mastoids < 3 Views Pr Side                            $9.23
70120   TC    Radex Mastoids < 3 Views Pr Side                           $24.36
70130         Radex Mastoids Compl Minimum 3 Views Pr Side               $48.00
70130   26    Radex Mastoids Compl Minimum 3 Views Pr Side               $16.98
70130   TC    Radex Mastoids Compl Minimum 3 Views Pr Side               $31.02
70134         Radex Int Aud Meati Compl                                  $46.18
70134   26    Radex Int Aud Meati Compl                                  $16.99
70134   TC    Radex Int Aud Meati Compl                                  $29.19

                                            Page 116
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                Amount
70140         Radex Facial B1S < 3 Views                                  $33.96
70140   26    Radex Facial B1S < 3 Views                                   $9.60
70140   TC    Radex Facial B1S < 3 Views                                  $24.36
70150         Radex Facial B1S Compl Minimum 3 Views                      $44.28
70150   26    Radex Facial B1S Compl Minimum 3 Views                      $13.28
70150   TC    Radex Facial B1S Compl Minimum 3 Views                      $31.00
70160         Radex Nsl B1S Compl Minimum 3 Views                         $28.75
70160   26    Radex Nsl B1S Compl Minimum 3 Views                          $8.85
70160   TC    Radex Nsl B1S Compl Minimum 3 Views                         $19.90
70170         Dacryocstograpy Nasolacrimal Dux Rs&I                       $52.39
70170   26    Dacryocstograpy Nasolacrimal Dux Rs&I                       $15.13
70170   TC    Dacryocstograpy Nasolacrimal Dux Rs&I                       $37.27
70171         Dacryocystography, Nasolacrimal Duct; Complete Procedure    $53.69
70171   26    Dacryocystography, Nasolacrimal Duct; Complete Procedure    $16.11
70171   TC    Dacryocystography, Nasolacrimal Duct; Complete Procedure    $37.58
70190         Radex Optic Foramina                                        $35.07
70190   26    Radex Optic Foramina                                        $10.71
70190   TC    Radex Optic Foramina                                        $24.36
70200         Radex Orbits Compl Minimum 4 Views                          $45.03
70200   26    Radex Orbits Compl Minimum 4 Views                          $14.03
70200   TC    Radex Orbits Compl Minimum 4 Views                          $31.00
70210         Radex Sinuses Paransl < 3 Views                             $33.21
70210   26    Radex Sinuses Paransl < 3 Views                              $8.86
70210   TC    Radex Sinuses Paransl < 3 Views                             $24.35
70220         Radex Sinuses Paransl Compl Minimum 3 Views                 $43.55
70220   26    Radex Sinuses Paransl Compl Minimum 3 Views                 $12.55
70220   TC    Radex Sinuses Paransl Compl Minimum 3 Views                 $31.00
70230         Rad Xm,Snses,Prnsl;Complete;W/Cntrst Stds,Sprv&Int          $58.24
70230   26    Rad Xm,Snses,Prnsl;Complete;W/Cntrst Stds,Sprv&Int          $17.47
70230   TC    Rad Xm,Snses,Prnsl;Complete;W/Cntrst Stds,Sprv&Int          $40.77
70231         Rad Xm Snses Prnsl,Comp W/Cntrst Stds,Comp Proc             $65.52
70231   26    Rad Xm Snses Prnsl,Comp W/Cntrst Stds,Comp Proc             $19.66
70231   TC    Rad Xm Snses Prnsl,Comp W/Cntrst Stds,Comp Proc             $45.86
70240         Radex Sella Turcica                                         $25.48
70240   26    Radex Sella Turcica                                          $9.60
70240   TC    Radex Sella Turcica                                         $15.88
70250         Radex Skl < 4 Views                                         $36.56
70250   26    Radex Skl < 4 Views                                         $12.19
70250   TC    Radex Skl < 4 Views                                         $24.37
70260         Radex Skl Compl Minimum 4 Views                             $52.06
70260   26    Radex Skl Compl Minimum 4 Views                             $16.98
70260   TC    Radex Skl Compl Minimum 4 Views                             $35.08
70300         Radex Teeth 1 View                                          $16.64
70300   26    Radex Teeth 1 View                                           $5.92
70300   TC    Radex Teeth 1 View                                          $10.72
70310         Radex Teeth Prtl Xm < Full Mouth                            $25.09
70310   26    Radex Teeth Prtl Xm < Full Mouth                             $9.22
70310   TC    Radex Teeth Prtl Xm < Full Mouth                            $15.87
70320         Radex Teeth Compl Full Mouth                                $42.42
70320   26    Radex Teeth Compl Full Mouth                                $11.44
70320   TC    Radex Teeth Compl Full Mouth                                $30.98
70328         Radex Tmprmand Jt Opn&Clsd Mouth Uni                        $28.03
70328   26    Radex Tmprmand Jt Opn&Clsd Mouth Uni                         $9.22
70328   TC    Radex Tmprmand Jt Opn&Clsd Mouth Uni                        $18.81
70330         Radex Tmprmand Jt Opn&Clsd Mouth Bi                         $45.36

                                           Page 117
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                Amount
70330    26   Radex Tmprmand Jt Opn&Clsd Mouth Bi                         $12.17
70330   TC    Radex Tmprmand Jt Opn&Clsd Mouth Bi                         $33.19
70332         Tmprmand Jt Arthg Rs&I                                     $109.85
70332   26    Tmprmand Jt Arthg Rs&I                                      $28.01
70332   TC    Tmprmand Jt Arthg Rs&I                                      $81.84
70333         Temporomandibular Joint Arthrography; Complete Procedure    $56.42
70333   26    Temporomandibular Joint Arthrography; Complete Procedure    $16.93
70333   TC    Temporomandibular Joint Arthrography; Complete Procedure    $39.49
70336         Mri Tmprmand Jt                                            $510.49
70336   26    Mri Tmprmand Jt                                             $75.09
70336   TC    Mri Tmprmand Jt                                            $435.40
70350         Cephalogram Orthodontic                                     $23.64
70350   26    Cephalogram Orthodontic                                      $9.23
70350   TC    Cephalogram Orthodontic                                     $14.41
70355         Orthopantogram                                              $33.24
70355   26    Orthopantogram                                              $10.71
70355   TC    Orthopantogram                                              $22.53
70360         Radex Nck Soft Tiss                                         $24.73
70360   26    Radex Nck Soft Tiss                                          $8.86
70360   TC    Radex Nck Soft Tiss                                         $15.87
70370         Radex Pharynx/Larx W/Fluor&/Magnification Tq                $67.06
70370   26    Radex Pharynx/Larx W/Fluor&/Magnification Tq                $16.22
70370   TC    Radex Pharynx/Larx W/Fluor&/Magnification Tq                $50.84
70371         Cplx Dynamic Pharyngeal&Sp Eval C/V Rec                    $125.19
70371   26    Cplx Dynamic Pharyngeal&Sp Eval C/V Rec                     $43.20
70371   TC    Cplx Dynamic Pharyngeal&Sp Eval C/V Rec                     $81.99
70373         Laryngograpy Cntrst Rs&I                                    $92.56
70373   26    Laryngograpy Cntrst Rs&I                                    $22.49
70373   TC    Laryngograpy Cntrst Rs&I                                    $70.07
70374         Laryngography, Contrast; Complete Procedure                 $74.62
70374   26    Laryngography, Contrast; Complete Procedure                 $22.39
70374   TC    Laryngography, Contrast; Complete Procedure                 $52.23
70380         Radex Salivary Glnd F/St1                                   $35.04
70380   26    Radex Salivary Glnd F/St1                                    $8.85
70380   TC    Radex Salivary Glnd F/St1                                   $26.19
70390         Sialograpy Rs&I                                             $89.59
70390   26    Sialograpy Rs&I                                             $19.54
70390   TC    Sialograpy Rs&I                                             $70.05
70391         Sialography; Complete Procedure                             $46.41
70391   26    Sialography; Complete Procedure                             $13.92
70391   TC    Sialography; Complete Procedure                             $32.49
70400         Orbitgrphy Air Positve Contrst Suprvsn/Intrptatn            $81.90
70400   26    Orbitgrphy Air Positve Contrst Suprvsn/Intrptatn            $24.57
70400   TC    Orbitgrphy Air Positve Contrst Suprvsn/Intrptatn            $57.33
70401         Orbigrpy Air Or Positive Cntrst;Comp Proc                  $154.17
70401   26    Orbigrpy Air Or Positive Cntrst;Comp Proc                   $46.25
70401   TC    Orbigrpy Air Or Positive Cntrst;Comp Proc                  $107.92
70450         Ct Head/Brn C-Matrl                                        $227.26
70450   26    Ct Head/Brn C-Matrl                                         $43.45
70450   TC    Ct Head/Brn C-Matrl                                        $183.81
70460         Ct Head/Brn C+ Matrl                                       $277.40
70460   26    Ct Head/Brn C+ Matrl                                        $57.48
70460   TC    Ct Head/Brn C+ Matrl                                       $219.92
70470         Ct Head/Brn C-/C+                                          $339.56
70470   26    Ct Head/Brn C-/C+                                           $64.45

                                           Page 118
                           MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                     Amount
70470   TC    Ct Head/Brn C-/C+                              $275.11
70480         Ct Orbit Sella/Post Fossa/Ear C-Matrl          $249.24
70480   26    Ct Orbit Sella/Post Fossa/Ear C-Matrl            $65.25
70480   TC    Ct Orbit Sella/Post Fossa/Ear C-Matrl          $183.99
70481         Ct Orbit Sella/Post Fossa/Ear C+ Matrl         $290.06
70481   26    Ct Orbit Sella/Post Fossa/Ear C+ Matrl           $70.02
70481   TC    Ct Orbit Sella/Post Fossa/Ear C+ Matrl         $220.04
70482         Ct Orbit Sella/Post Fossa/Ear C-/C+            $348.47
70482   26    Ct Orbit Sella/Post Fossa/Ear C-/C+              $73.32
70482   TC    Ct Orbit Sella/Post Fossa/Ear C-/C+            $275.15
70486         Ct Maxlfcl Area C-Matrl                        $241.78
70486   26    Ct Maxlfcl Area C-Matrl                          $57.86
70486   TC    Ct Maxlfcl Area C-Matrl                        $183.92
70487         Ct Maxlfcl Area C+ Matrl                       $285.98
70487   26    Ct Maxlfcl Area C+ Matrl                         $65.98
70487   TC    Ct Maxlfcl Area C+ Matrl                       $220.00
70488         Ct Maxlfcl Area C-/C+                          $346.99
70488   26    Ct Maxlfcl Area C-/C+                            $71.83
70488   TC    Ct Maxlfcl Area C-/C+                          $275.16
70490         Ct Soft Tiss Nck C-Matrl                       $249.24
70490   26    Ct Soft Tiss Nck C-Matrl                         $65.25
70490   TC    Ct Soft Tiss Nck C-Matrl                       $183.99
70491         Ct Soft Tiss Nck C+ Matrl                      $290.06
70491   26    Ct Soft Tiss Nck C+ Matrl                        $70.02
70491   TC    Ct Soft Tiss Nck C+ Matrl                      $220.04
70492         Ct Soft Tiss Nck C-/C+                         $348.47
70492   26    Ct Soft Tiss Nck C-/C+                           $73.32
70492   TC    Ct Soft Tiss Nck C-/C+                         $275.15
70496         Cta Head C-/C+                                 $502.72
70496   26    Cta Head C-/C+                                   $89.13
70496   TC    Cta Head C-/C+                                 $413.59
70498         Cta Nck C-/C+ Post-Pxessing                    $502.72
70498   26    Cta Nck C-/C+ Post-Pxessing                      $89.13
70498   TC    Cta Nck C-/C+ Post-Pxessing                    $413.59
70540         Mri Orbit Face &/Neck W/O Contrast             $494.82
70540   26    Mri Orbit Face &/Neck W/O Contrast               $67.59
70540   TC    Mri Orbit Face &/Neck W/O Contrast             $427.23
70541         Mri Angio Head/Neck W/Wo Contrast              $518.80
70541   26    Mri Angio Head/Neck W/Wo Contrast              $155.64
70541   TC    Mri Angio Head/Neck W/Wo Contrast              $363.16
70542         Mri Orbit Face&Nck C+ Matrl                    $594.01
70542   26    Mri Orbit Face&Nck C+ Matrl                      $81.20
70542   TC    Mri Orbit Face&Nck C+ Matrl                    $512.81
70543         Mri Orbit Face&Nck C-/C+                      $1,055.81
70543   26    Mri Orbit Face&Nck C-/C+                       $107.90
70543   TC    Mri Orbit Face&Nck C-/C+                       $947.91
70544         Mra Head C-Matrl                               $495.94
70544   26    Mra Head C-Matrl                                 $60.70
70544   TC    Mra Head C-Matrl                               $435.24
70545         Mra Head C+ Matrl                              $495.94
70545   26    Mra Head C+ Matrl                                $60.70
70545   TC    Mra Head C+ Matrl                              $435.24
70546         Mra Head C-/C+                                 $938.08
70546   26    Mra Head C-/C+                                   $91.37
70546   TC    Mra Head C-/C+                                 $846.71

                                             Page 119
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                      Amount
70547         Mra Nck C-Matrl                                 $495.94
70547   26    Mra Nck C-Matrl                                   $60.70
70547   TC    Mra Nck C-Matrl                                 $435.24
70548         Mra Nck C+ Matrl                                $495.94
70548   26    Mra Nck C+ Matrl                                  $60.70
70548   TC    Mra Nck C+ Matrl                                $435.24
70549         Mra Nck C-/C+                                   $938.08
70549   26    Mra Nck C-/C+                                     $91.37
70549   TC    Mra Nck C-/C+                                   $846.71
70551         Mri Brn Brn Stem C-Matrl                        $510.86
70551   26    Mri Brn Brn Stem C-Matrl                          $75.45
70551   TC    Mri Brn Brn Stem C-Matrl                        $435.41
70552         Mri Brn Brn Stem C+ Matrl                       $613.16
70552   26    Mri Brn Brn Stem C+ Matrl                         $90.93
70552   TC    Mri Brn Brn Stem C+ Matrl                       $522.23
70553         Mri Brn Brn Stem C-/C+                         $1,086.97
70553   26    Mri Brn Brn Stem C-/C+                          $119.89
70553   TC    Mri Brn Brn Stem C-/C+                          $967.08
70557         Mri Brn Opn Icra Px C-Matrl                        $0.00
70557   26    Mri Brn Opn Icra Px C-Matrl                     $147.32
70557   TC    Mri Brn Opn Icra Px C-Matrl                        $0.00
70558         Mri Brn Opn Icra Px C+ Matrl                       $0.00
70558   26    Mri Brn Opn Icra Px C+ Matrl                    $162.99
70558   TC    Mri Brn Opn Icra Px C+ Matrl                       $0.00
70559         Mri Brn Opn Icra Px C-/C+                          $0.00
70559   26    Mri Brn Opn Icra Px C-/C+                       $163.80
70559   TC    Mri Brn Opn Icra Px C-/C+                          $0.00
71000         Rad Xm, Chest Menifilm                            $10.92
71000   26    Rad Xm, Chest Menifilm                             $3.28
71000   TC    Rad Xm, Chest Menifilm                             $7.64
71010         Radex Ch 1 View Frnt                              $27.30
71010   26    Radex Ch 1 View Frnt                               $9.22
71010   TC    Radex Ch 1 View Frnt                              $18.08
71015         Radex Ch Stereo Frnt                              $30.61
71015   26    Radex Ch Stereo Frnt                              $10.70
71015   TC    Radex Ch Stereo Frnt                              $19.91
71020         Radex Ch 2 Views Frnt&Lat                         $35.45
71020   26    Radex Ch 2 Views Frnt&Lat                         $11.08
71020   TC    Radex Ch 2 Views Frnt&Lat                         $24.37
71021         Radex Ch 2 Views Frnt&Lat Apical Lordotic Px      $42.83
71021   26    Radex Ch 2 Views Frnt&Lat Apical Lordotic Px      $13.66
71021   TC    Radex Ch 2 Views Frnt&Lat Apical Lordotic Px      $29.17
71022         Radex Ch 2 Views Frnt&Lat Oblq Prjcj              $45.10
71022   26    Radex Ch 2 Views Frnt&Lat Oblq Prjcj              $15.90
71022   TC    Radex Ch 2 Views Frnt&Lat Oblq Prjcj              $29.20
71023         Radex Ch 2 Views Frnt&Lat Fluor                   $50.63
71023   26    Radex Ch 2 Views Frnt&Lat Fluor                   $19.59
71023   TC    Radex Ch 2 Views Frnt&Lat Fluor                   $31.04
71030         Radex Ch Compl Minimum 4 Views                    $46.52
71030   26    Radex Ch Compl Minimum 4 Views                    $15.51
71030   TC    Radex Ch Compl Minimum 4 Views                    $31.01
71034         Radex Ch Compl Minimum 4 Views W/Fluor            $79.67
71034   26    Radex Ch Compl Minimum 4 Views W/Fluor            $23.61
71034   TC    Radex Ch Compl Minimum 4 Views W/Fluor            $56.06
71035         Radex Ch Spec Views                               $29.12

                                            Page 120
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
71035    26   Radex Ch Spec Views                                              $9.22
71035   TC    Radex Ch Spec Views                                             $19.90
71036         Needle Bx Intrathoracic Les-S & I                               $92.82
71036   26    Needle Bx Intrathoracic Les-S & I                               $27.85
71036   TC    Needle Bx Intrathoracic Les-S & I                               $64.97
71037         Needle Biopsy Of Intrathoracic Lesion, Including Follow-Up F   $223.73
71037   26    Needle Biopsy Of Intrathoracic Lesion, Including Follow-Up F    $67.12
71037   TC    Needle Biopsy Of Intrathoracic Lesion, Including Follow-Up F   $156.61
71038         Fluoroscopic Localization For Transbronchial Biopsy Or Brush    $91.40
71038   26    Fluoroscopic Localization For Transbronchial Biopsy Or Brush    $27.42
71038   TC    Fluoroscopic Localization For Transbronchial Biopsy Or Brush    $63.98
71040         Bronchograpy Uni Rs&I                                           $86.79
71040   26    Bronchograpy Uni Rs&I                                           $29.92
71040   TC    Bronchograpy Uni Rs&I                                           $56.87
71041         Bronchography, Unilateral; Complete Procedure                   $82.81
71041   TC    Bronchography, Unilateral; Complete Procedure                   $57.97
71060         Bronchograpy Bi Rs&I                                           $124.38
71060   26    Bronchograpy Bi Rs&I                                            $38.01
71060   TC    Bronchograpy Bi Rs&I                                            $86.37
71061         Bronchography, Bilateral; Complete Procedure                   $118.30
71061   TC    Bronchography, Bilateral; Complete Procedure                    $82.81
71090         Insj Pm Fluor&Radiograpy Rs&I                                   $94.83
71090   26    Insj Pm Fluor&Radiograpy Rs&I                                   $28.41
71090   TC    Insj Pm Fluor&Radiograpy Rs&I                                   $66.42
71100         Radex Ribs Uni 2 Views                                          $33.62
71100   26    Radex Ribs Uni 2 Views                                          $11.08
71100   TC    Radex Ribs Uni 2 Views                                          $22.54
71101         Radex Ribs Uni W/Posteroant Ch Minimum 3 Views                  $39.87
71101   26    Radex Ribs Uni W/Posteroant Ch Minimum 3 Views                  $13.66
71101   TC    Radex Ribs Uni W/Posteroant Ch Minimum 3 Views                  $26.21
71110         Radex Ribs Bi 3 Views                                           $44.66
71110   26    Radex Ribs Bi 3 Views                                           $13.66
71110   TC    Radex Ribs Bi 3 Views                                           $31.00
71111         Radex Ribs Bi W/Posteroant Ch Minimum 4 Views                   $51.31
71111   26    Radex Ribs Bi W/Posteroant Ch Minimum 4 Views                   $16.24
71111   TC    Radex Ribs Bi W/Posteroant Ch Minimum 4 Views                   $35.07
71120         Radex Sternum Minimum 2 Views                                   $35.79
71120   26    Radex Sternum Minimum 2 Views                                   $10.33
71120   TC    Radex Sternum Minimum 2 Views                                   $25.46
71130         Radex Strnclav Jt/Jts Minimum 3 Views                           $38.73
71130   26    Radex Strnclav Jt/Jts Minimum 3 Views                           $11.07
71130   TC    Radex Strnclav Jt/Jts Minimum 3 Views                           $27.66
71250         Ct Thorax C-Matrl                                              $288.79
71250   26    Ct Thorax C-Matrl                                               $58.94
71250   TC    Ct Thorax C-Matrl                                              $229.85
71260         Ct Thorax C+ Matrl                                             $337.67
71260   26    Ct Thorax C+ Matrl                                              $62.60
71260   TC    Ct Thorax C+ Matrl                                             $275.07
71270         Ct Thorax C-/C+                                                $413.79
71270   26    Ct Thorax C-/C+                                                 $69.93
71270   TC    Ct Thorax C-/C+                                                $343.86
71275         Cta Ch C-/C+ Post-Pxessing                                     $566.94
71275   26    Cta Ch C-/C+ Post-Pxessing                                      $96.27
71275   TC    Cta Ch C-/C+ Post-Pxessing                                     $470.67
71550         Mri Ch C-Matrl                                                 $502.83

                                             Page 121
                         MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                      Amount
71550    26   Mri Ch C-Matrl                                    $73.16
71550   TC    Mri Ch C-Matrl                                  $429.67
71551         Mri Ch C+ Matrl                                 $602.02
71551   26    Mri Ch C+ Matrl                                   $87.11
71551   TC    Mri Ch C+ Matrl                                 $514.91
71552         Mri Ch C-/C+                                   $1,055.32
71552   26    Mri Ch C-/C+                                    $113.76
71552   TC    Mri Ch C-/C+                                    $941.56
71555         Mra Ch C+-Matrl                                 $528.01
71555   26    Mra Ch C+-Matrl                                   $92.40
71555   TC    Mra Ch C+-Matrl                                 $435.61
72010         Radex Spi Entire Surv Std Anteropost&Lat          $63.96
72010   26    Radex Spi Entire Surv Std Anteropost&Lat          $23.66
72010   TC    Radex Spi Entire Surv Std Anteropost&Lat          $40.30
72020         Radex Spi 1 View Spec Lvl                         $23.62
72020   26    Radex Spi 1 View Spec Lvl                          $7.75
72020   TC    Radex Spi 1 View Spec Lvl                         $15.87
72040         Radex Spi Crv 2/3 Views                           $34.71
72040   26    Radex Spi Crv 2/3 Views                           $11.08
72040   TC    Radex Spi Crv 2/3 Views                           $23.63
72050         Radex Spi Crv Minimum 4 Views                     $50.98
72050   26    Radex Spi Crv Minimum 4 Views                     $15.89
72050   TC    Radex Spi Crv Minimum 4 Views                     $35.09
72052         Radex Spi Crv Compl W/Oblq&Flexion&/Xtn Stds      $62.34
72052   26    Radex Spi Crv Compl W/Oblq&Flexion&/Xtn Stds      $18.45
72052   TC    Radex Spi Crv Compl W/Oblq&Flexion&/Xtn Stds      $43.89
72069         Radex Spi Thoracolmbr Standing Scoliosis          $30.66
72069   26    Radex Spi Thoracolmbr Standing Scoliosis          $11.82
72069   TC    Radex Spi Thoracolmbr Standing Scoliosis          $18.84
72070         Radex Spi Thrc 2 Views                            $36.54
72070   26    Radex Spi Thrc 2 Views                            $11.07
72070   TC    Radex Spi Thrc 2 Views                            $25.47
72072         Radex Spi Thrc 3 Views                            $40.23
72072   26    Radex Spi Thrc 3 Views                            $11.07
72072   TC    Radex Spi Thrc 3 Views                            $29.16
72074         Radex Spi Thrc Minimum 4 Views                    $46.85
72074   26    Radex Spi Thrc Minimum 4 Views                    $11.07
72074   TC    Radex Spi Thrc Minimum 4 Views                    $35.78
72080         Radex Spi Thoracolmbr 2 Views                     $37.68
72080   26    Radex Spi Thoracolmbr 2 Views                     $11.45
72080   TC    Radex Spi Thoracolmbr 2 Views                     $26.23
72090         Radex Spi Scoliosis Std W/Sup&Erc Stds            $40.65
72090   26    Radex Spi Scoliosis Std W/Sup&Erc Stds            $14.41
72090   TC    Radex Spi Scoliosis Std W/Sup&Erc Stds            $26.24
72100         Radex Spi Lumbosac 2/3 Views                      $37.68
72100   26    Radex Spi Lumbosac 2/3 Views                      $11.45
72100   TC    Radex Spi Lumbosac 2/3 Views                      $26.23
72110         Radex Spi Lumbosac Minimum 4 Views                $51.71
72110   26    Radex Spi Lumbosac Minimum 4 Views                $15.88
72110   TC    Radex Spi Lumbosac Minimum 4 Views                $35.83
72114         Radex Spi Lumbosac Compl W/Bending Views          $65.35
72114   26    Radex Spi Lumbosac Compl W/Bending Views          $19.20
72114   TC    Radex Spi Lumbosac Compl W/Bending Views          $46.15
72120         Radex Spi Lumbosac Bending Minimum 4 Views        $46.53
72120   26    Radex Spi Lumbosac Bending Minimum 4 Views        $11.45

                                          Page 122
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                 Amount
72120   TC    Radex Spi Lumbosac Bending Minimum 4 Views                   $35.08
72125         Ct Crv Spi C-Matrl                                          $288.79
72125   26    Ct Crv Spi C-Matrl                                           $58.94
72125   TC    Ct Crv Spi C-Matrl                                          $229.85
72126         Ct Crv Spi C+ Matrl                                         $336.56
72126   26    Ct Crv Spi C+ Matrl                                          $61.49
72126   TC    Ct Crv Spi C+ Matrl                                         $275.07
72127         Ct Crv Spi C-/C+                                            $408.22
72127   26    Ct Crv Spi C-/C+                                             $64.42
72127   TC    Ct Crv Spi C-/C+                                            $343.80
72128         Ct Thrc Spi C-Matrl                                         $288.79
72128   26    Ct Thrc Spi C-Matrl                                          $58.94
72128   TC    Ct Thrc Spi C-Matrl                                         $229.85
72129         Ct Thrc Spi C+ Matrl                                        $336.56
72129   26    Ct Thrc Spi C+ Matrl                                         $61.49
72129   TC    Ct Thrc Spi C+ Matrl                                        $275.07
72130         Ct Thrc Spi C-/C+                                           $408.22
72130   26    Ct Thrc Spi C-/C+                                            $64.42
72130   TC    Ct Thrc Spi C-/C+                                           $343.80
72131         Ct Lmbr Spi C-Matrl                                         $288.79
72131   26    Ct Lmbr Spi C-Matrl                                          $58.94
72131   TC    Ct Lmbr Spi C-Matrl                                         $229.85
72132         Ct Lmbr Spi C+ Matrl                                        $337.33
72132   26    Ct Lmbr Spi C+ Matrl                                         $62.24
72132   TC    Ct Lmbr Spi C+ Matrl                                        $275.09
72133         Ct Lmbr Spi C-/C+                                           $408.59
72133   26    Ct Lmbr Spi C-/C+                                            $64.80
72133   TC    Ct Lmbr Spi C-/C+                                           $343.79
72140         Magnetic Resonance (Eg, Proton) Imaging,                    $666.00
72140   26    Magnetic Resonance (Eg, Proton) Imaging,                    $199.80
72140   TC    Magnetic Resonance (Eg, Proton) Imaging,                    $466.20
72141         Mri Spi Canal&Cnts Crv C-Matrl                              $516.80
72141   26    Mri Spi Canal&Cnts Crv C-Matrl                               $81.34
72141   TC    Mri Spi Canal&Cnts Crv C-Matrl                              $435.46
72142         Mri Spi Canal&Cnts Crv C+ Matrl                             $620.99
72142   26    Mri Spi Canal&Cnts Crv C+ Matrl                              $98.68
72142   TC    Mri Spi Canal&Cnts Crv C+ Matrl                             $522.31
72143         Magnetic Resonance (Eg, Proton) Imaging, Spinal Canal And   $515.59
72143   26    Magnetic Resonance (Eg, Proton) Imaging, Spinal Canal And   $154.68
72143   TC    Magnetic Resonance (Eg, Proton) Imaging, Spinal Canal And   $360.91
72144         Magnetic Resonance (Eg, Proton) Imaging, Spinal Canal And   $507.69
72144   26    Magnetic Resonance (Eg, Proton) Imaging, Spinal Canal And   $152.31
72144   TC    Magnetic Resonance (Eg, Proton) Imaging, Spinal Canal And   $355.38
72145         Cmptrzd Axl Tmgraphy, Spne;W/Wo Cntrst Mat                  $345.80
72145   26    Cmptrzd Axl Tmgraphy, Spne;W/Wo Cntrst Mat                  $103.74
72145   TC    Cmptrzd Axl Tmgraphy, Spne;W/Wo Cntrst Mat                  $242.06
72146         Mri Spi Canal&Cnts Thrc C-Matrl                             $563.75
72146   26    Mri Spi Canal&Cnts Thrc C-Matrl                              $80.95
72146   TC    Mri Spi Canal&Cnts Thrc C-Matrl                             $482.80
72147         Mri Spi Canal&Cnts Thrc C+ Matrl                            $620.62
72147   26    Mri Spi Canal&Cnts Thrc C+ Matrl                             $98.31
72147   TC    Mri Spi Canal&Cnts Thrc C+ Matrl                            $522.31
72148         Mri Spi Canal&Cnts Lmbr C-Matrl                             $558.17
72148   26    Mri Spi Canal&Cnts Lmbr C-Matrl                              $75.41
72148   TC    Mri Spi Canal&Cnts Lmbr C-Matrl                             $482.76

                                           Page 123
                         MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                   Amount
72149         Mri Spi Canal&Cnts Lmbr C+ Matrl             $613.94
72149   26    Mri Spi Canal&Cnts Lmbr C+ Matrl               $91.66
72149   TC    Mri Spi Canal&Cnts Lmbr C+ Matrl             $522.28
72156         Mri Spi Canal&Cnts C-/C+ Crv                $1,097.77
72156   26    Mri Spi Canal&Cnts C-/C+ Crv                 $130.63
72156   TC    Mri Spi Canal&Cnts C-/C+ Crv                 $967.14
72157         Mri Spi Canal&Cnts C-/C+                    $1,097.77
72157   26    Mri Spi Canal&Cnts C-/C+                     $130.63
72157   TC    Mri Spi Canal&Cnts C-/C+                     $967.14
72158         Mri Spi Canal&Cnts C-/C+ Lmbr               $1,087.37
72158   26    Mri Spi Canal&Cnts C-/C+ Lmbr                $120.26
72158   TC    Mri Spi Canal&Cnts C-/C+ Lmbr                $967.11
72159         Mra Spi Canal&Cnts C+-Matrl                  $569.11
72159   26    Mra Spi Canal&Cnts C+-Matrl                    $95.33
72159   TC    Mra Spi Canal&Cnts C+-Matrl                  $473.78
72170         Radex Pelvis 1/2 Views                         $28.75
72170   26    Radex Pelvis 1/2 Views                          $8.85
72170   TC    Radex Pelvis 1/2 Views                         $19.90
72180         Radiologic Examination, Pelvis                  $0.00
72190         Radex Pelvis Compl Minimum 3 Views             $36.90
72190   26    Radex Pelvis Compl Minimum 3 Views             $10.70
72190   TC    Radex Pelvis Compl Minimum 3 Views             $26.20
72191         Cta Pelvis C-/C+ Post-Pxessing               $548.96
72191   26    Cta Pelvis C-/C+ Post-Pxessing                 $91.13
72191   TC    Cta Pelvis C-/C+ Post-Pxessing               $457.83
72192         Ct Pelvis C-Matrl                            $285.44
72192   26    Ct Pelvis C-Matrl                              $55.60
72192   TC    Ct Pelvis C-Matrl                            $229.84
72193         Ct Pelvis C+ Matrl                           $325.15
72193   26    Ct Pelvis C+ Matrl                             $58.92
72193   TC    Ct Pelvis C+ Matrl                           $266.23
72194         Ct Pelvis C-/C+                              $391.22
72194   26    Ct Pelvis C-/C+                                $61.81
72194   TC    Ct Pelvis C-/C+                              $329.41
72195         Mri Pelvis C-Matrl                           $503.24
72195   26    Mri Pelvis C-Matrl                             $73.52
72195   TC    Mri Pelvis C-Matrl                           $429.72
72196         Mri Pelvis C+ Matrl                          $601.61
72196   26    Mri Pelvis C+ Matrl                            $86.75
72196   TC    Mri Pelvis C+ Matrl                          $514.86
72197         Mri Pelvis C-/C+                            $1,065.09
72197   26    Mri Pelvis C-/C+                             $113.86
72197   TC    Mri Pelvis C-/C+                             $951.23
72198         Mra Pelvis C+-Matrl                          $530.56
72198   26    Mra Pelvis C+-Matrl                            $94.97
72198   TC    Mra Pelvis C+-Matrl                          $435.59
72200         Radex Si Jts < 3 Views                         $28.75
72200   26    Radex Si Jts < 3 Views                          $8.85
72200   TC    Radex Si Jts < 3 Views                         $19.90
72202         Radex Si Jts 3/More Views                      $33.96
72202   26    Radex Si Jts 3/More Views                       $9.60
72202   TC    Radex Si Jts 3/More Views                      $24.36
72220         Radex Sacrum&Coccyx Minimum 2 Views            $31.39
72220   26    Radex Sacrum&Coccyx Minimum 2 Views             $8.86
72220   TC    Radex Sacrum&Coccyx Minimum 2 Views            $22.53

                                        Page 124
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
72240         Myelograpy Crv Rs&I                                            $230.96
72240   26    Myelograpy Crv Rs&I                                             $46.05
72240   TC    Myelograpy Crv Rs&I                                            $184.91
72241         Myelography, Cervical; Complete Procedure                      $104.65
72241   26    Myelography, Cervical; Complete Procedure                       $31.40
72241   TC    Myelography, Cervical; Complete Procedure                       $73.26
72255         Myelograpy Thrc Rs&I                                           $213.67
72255   26    Myelograpy Thrc Rs&I                                            $45.68
72255   TC    Myelograpy Thrc Rs&I                                           $167.99
72256         Myelography, Thoracic; Complete Procedure                      $104.65
72256   TC    Myelography, Thoracic; Complete Procedure                       $73.26
72265         Myelograpy Lumbosac Rs&I                                       $200.82
72265   26    Myelograpy Lumbosac Rs&I                                        $42.01
72265   TC    Myelograpy Lumbosac Rs&I                                       $158.81
72266         Myelography, Lumbosacral; Complete Procedure                   $104.65
72266   26    Myelography, Lumbosacral; Complete Procedure                    $31.40
72266   TC    Myelography, Lumbosacral; Complete Procedure                    $73.26
72270         Myelograpy 2/More Regions Rs&I                                 $304.79
72270   26    Myelograpy 2/More Regions Rs&I                                  $67.08
72270   TC    Myelograpy 2/More Regions Rs&I                                 $237.71
72271         Myelography, Entire Spinal Canal; Complete Procedure           $163.80
72271   26    Myelography, Entire Spinal Canal; Complete Procedure            $49.14
72271   TC    Myelography, Entire Spinal Canal; Complete Procedure           $114.66
72275         Epidurograpy Rs&I                                              $122.94
72275   26    Epidurograpy Rs&I                                               $37.03
72275   TC    Epidurograpy Rs&I                                               $85.91
72285         Diskograpy Crv/Thrc Rs&I                                       $383.91
72285   26    Diskograpy Crv/Thrc Rs&I                                        $58.51
72285   TC    Diskograpy Crv/Thrc Rs&I                                       $325.40
72286         Diskography, Cervical; Complete Procedure                      $109.20
72286   TC    Diskography, Cervical; Complete Procedure                       $76.44
72295         Diskograpy Lmbr Rs&I                                           $346.91
72295   26    Diskograpy Lmbr Rs&I                                            $42.32
72295   TC    Diskograpy Lmbr Rs&I                                           $304.59
72296         Diskography, Lumbar; Complete Procedure                        $109.20
72296   TC    Diskography, Lumbar; Complete Procedure                         $76.44
73000         Radex Clav Compl                                                $28.01
73000   26    Radex Clav Compl                                                 $8.11
73000   TC    Radex Clav Compl                                                $19.90
73010         Radex Scapula Compl                                             $28.75
73010   26    Radex Scapula Compl                                              $8.85
73010   TC    Radex Scapula Compl                                             $19.90
73020         Radex Sho 1 View                                                $25.81
73020   26    Radex Sho 1 View                                                 $7.74
73020   TC    Radex Sho 1 View                                                $18.07
73030         Radex Sho Compl Minimum 2 Views                                 $31.76
73030   26    Radex Sho Compl Minimum 2 Views                                  $9.23
73030   TC    Radex Sho Compl Minimum 2 Views                                 $22.53
73040         Radex Sho Arthg Rs&I                                           $109.93
73040   26    Radex Sho Arthg Rs&I                                            $28.03
73040   TC    Radex Sho Arthg Rs&I                                            $81.90
73041         Radiologic Examination, Shoulder, Arthrography; Complete Pro    $58.24
73041   26    Radiologic Examination, Shoulder, Arthrography; Complete Pro    $17.47
73041   TC    Radiologic Examination, Shoulder, Arthrography; Complete Pro    $40.77
73050         Radex Acromclav Jts Bi +-W8Ed Distrcj                           $36.93

                                            Page 125
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
73050    26   Radex Acromclav Jts Bi +-W8Ed Distrcj                           $10.71
73050   TC    Radex Acromclav Jts Bi +-W8Ed Distrcj                           $26.22
73060         Radex Hum Minimum 2 Views                                       $31.39
73060   26    Radex Hum Minimum 2 Views                                        $8.86
73060   TC    Radex Hum Minimum 2 Views                                       $22.53
73070         Radex Elbw 2 Views                                              $27.64
73070   26    Radex Elbw 2 Views                                               $7.74
73070   TC    Radex Elbw 2 Views                                              $19.90
73080         Radex Elbw Compl Minimum 3 Views                                $31.39
73080   26    Radex Elbw Compl Minimum 3 Views                                 $8.86
73080   TC    Radex Elbw Compl Minimum 3 Views                                $22.53
73085         Radex Elbw Arthg Rs&I                                          $110.30
73085   26    Radex Elbw Arthg Rs&I                                           $28.40
73085   TC    Radex Elbw Arthg Rs&I                                           $81.90
73086         Radiologic Examination, Elbow, Arthrography; Complete Proced   $118.30
73086   TC    Radiologic Examination, Elbow, Arthrography; Complete Proced    $82.81
73090         Radex F/Arm 2 Views                                             $28.01
73090   26    Radex F/Arm 2 Views                                              $8.11
73090   TC    Radex F/Arm 2 Views                                             $19.90
73092         Radex Uxtr Inft Minimum 2 Views                                 $26.91
73092   26    Radex Uxtr Inft Minimum 2 Views                                  $8.11
73092   TC    Radex Uxtr Inft Minimum 2 Views                                 $18.80
73100         Radex Wrst 2 Views                                              $27.69
73100   26    Radex Wrst 2 Views                                               $8.86
73100   TC    Radex Wrst 2 Views                                              $18.83
73110         Radex Wrst Compl Minimum 3 Views                                $29.11
73110   26    Radex Wrst Compl Minimum 3 Views                                 $8.84
73110   TC    Radex Wrst Compl Minimum 3 Views                                $20.27
73115         Radex Wrst Arthg Rs&I                                           $90.49
73115   26    Radex Wrst Arthg Rs&I                                           $28.44
73115   TC    Radex Wrst Arthg Rs&I                                           $62.05
73116         Radiologic Examination, Wrist, Arthrography; Complete Proced    $22.75
73116   26    Radiologic Examination, Wrist, Arthrography; Complete Proced     $6.83
73116   TC    Radiologic Examination, Wrist, Arthrography; Complete Proced    $15.93
73120         Radex Hand 2 Views                                              $26.91
73120   26    Radex Hand 2 Views                                               $8.11
73120   TC    Radex Hand 2 Views                                              $18.80
73130         Radex Hand Minimum 3 Views                                      $29.11
73130   26    Radex Hand Minimum 3 Views                                       $8.84
73130   TC    Radex Hand Minimum 3 Views                                      $20.27
73140         Radex Fngr Minimum 2 Views                                      $22.51
73140   26    Radex Fngr Minimum 2 Views                                       $6.64
73140   TC    Radex Fngr Minimum 2 Views                                      $15.87
73200         Ct Uxtr C-Matrl                                                $247.94
73200   26    Ct Uxtr C-Matrl                                                 $55.64
73200   TC    Ct Uxtr C-Matrl                                                $192.30
73201         Ct Uxtr C+ Matrl                                               $288.79
73201   26    Ct Uxtr C+ Matrl                                                $58.94
73201   TC    Ct Uxtr C+ Matrl                                               $229.85
73202         Ct Uxtr C-/C+                                                  $350.92
73202   26    Ct Uxtr C-/C+                                                   $62.22
73202   TC    Ct Uxtr C-/C+                                                  $288.70
73206         Cta Uxtr C-/C+ Post-Pxessing                                   $509.52
73206   26    Cta Uxtr C-/C+ Post-Pxessing                                    $90.80
73206   TC    Cta Uxtr C-/C+ Post-Pxessing                                   $418.72

                                            Page 126
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
73218         Mri Uxtr Oth/Thn Jt C-Matrl                                     $494.82
73218   26    Mri Uxtr Oth/Thn Jt C-Matrl                                       $67.59
73218   TC    Mri Uxtr Oth/Thn Jt C-Matrl                                     $427.23
73219         Mri Uxtr Oth/Thn Jt C+ Matrl                                    $594.01
73219   26    Mri Uxtr Oth/Thn Jt C+ Matrl                                      $81.20
73219   TC    Mri Uxtr Oth/Thn Jt C+ Matrl                                    $512.81
73220         Mri Uxtr Oth/Thn Jt C-/C+                                      $1,056.63
73220   26    Mri Uxtr Oth/Thn Jt C-/C+                                       $108.62
73220   TC    Mri Uxtr Oth/Thn Jt C-/C+                                       $948.01
73221         Mri Any Jt Uxtr C-Matrl                                         $494.82
73221   26    Mri Any Jt Uxtr C-Matrl                                           $67.59
73221   TC    Mri Any Jt Uxtr C-Matrl                                         $427.23
73222         Mri Any Jt Uxtr C+ Matrl                                        $594.01
73222   26    Mri Any Jt Uxtr C+ Matrl                                          $81.20
73222   TC    Mri Any Jt Uxtr C+ Matrl                                        $512.81
73223         Mri Any Jt Uxtr C-/C+                                          $1,055.81
73223   26    Mri Any Jt Uxtr C-/C+                                           $107.90
73223   TC    Mri Any Jt Uxtr C-/C+                                           $947.91
73225         Mra Uxtr C+-Matrl                                               $519.18
73225   26    Mra Uxtr C+-Matrl                                                 $92.05
73225   TC    Mra Uxtr C+-Matrl                                               $427.13
73500         Radex Hip Uni 1 View                                              $26.92
73500   26    Radex Hip Uni 1 View                                               $8.85
73500   TC    Radex Hip Uni 1 View                                              $18.07
73510         Radex Hip Uni Compl Minimum 2 Views                               $33.65
73510   26    Radex Hip Uni Compl Minimum 2 Views                               $11.09
73510   TC    Radex Hip Uni Compl Minimum 2 Views                               $22.56
73520         Radex Hips Bi 2 Views Anteropost Pelvis                           $39.90
73520   26    Radex Hips Bi 2 Views Anteropost Pelvis                           $13.67
73520   TC    Radex Hips Bi 2 Views Anteropost Pelvis                           $26.23
73525         Radex Hip Arthg Rs&I                                            $109.93
73525   26    Radex Hip Arthg Rs&I                                              $28.03
73525   TC    Radex Hip Arthg Rs&I                                              $81.90
73526         Radiologic Examination, Hip, Arthrography; Complete Procedur    $145.16
73526   TC    Radiologic Examination, Hip, Arthrography; Complete Procedur    $101.61
73530         Radex Hip Oprative Px                                             $34.69
73530   26    Radex Hip Oprative Px                                             $14.76
73530   TC    Radex Hip Oprative Px                                             $19.93
73540         Radex Pelvis&Hips Inft/Chld Minimum 2 Views                       $33.28
73540   26    Radex Pelvis&Hips Inft/Chld Minimum 2 Views                       $10.72
73540   TC    Radex Pelvis&Hips Inft/Chld Minimum 2 Views                       $22.56
73542         Rad Xm Si Jt Arthg Rs&I                                         $111.07
73542   26    Rad Xm Si Jt Arthg Rs&I                                           $29.16
73542   TC    Rad Xm Si Jt Arthg Rs&I                                           $81.91
73550         Radex Femur 2 Views                                               $31.39
73550   26    Radex Femur 2 Views                                                $8.86
73550   TC    Radex Femur 2 Views                                               $22.53
73560         Radex Kne 1/2 Views                                               $29.15
73560   26    Radex Kne 1/2 Views                                                $9.23
73560   TC    Radex Kne 1/2 Views                                               $19.92
73562         Radex Kne 3 Views                                                 $32.17
73562   26    Radex Kne 3 Views                                                  $9.62
73562   TC    Radex Kne 3 Views                                                 $22.55
73564         Radex Kne Compl 4/More Views                                      $36.22
73564   26    Radex Kne Compl 4/More Views                                      $11.83

                                            Page 127
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
73564   TC    Radex Kne Compl 4/More Views                                    $24.39
73565         Radex Kne Bth Knes Standing Anteropost                          $28.06
73565   26    Radex Kne Bth Knes Standing Anteropost                           $9.23
73565   TC    Radex Kne Bth Knes Standing Anteropost                          $18.83
73580         Radex Kne Arthg Rs&I                                           $129.73
73580   26    Radex Kne Arthg Rs&I                                            $28.01
73580   TC    Radex Kne Arthg Rs&I                                           $101.72
73581         Radiologic Examination, Knee, Arthrography; Complete Procedu    $82.81
73581   TC    Radiologic Examination, Knee, Arthrography; Complete Procedu    $57.97
73590         Radex Tibfib 2 Views                                            $28.75
73590   26    Radex Tibfib 2 Views                                             $8.85
73590   TC    Radex Tibfib 2 Views                                            $19.90
73592         Radex Lxtr Inft Minimum 2 Views                                 $27.28
73592   26    Radex Lxtr Inft Minimum 2 Views                                  $8.48
73592   TC    Radex Lxtr Inft Minimum 2 Views                                 $18.80
73600         Radex Ankle 2 Views                                             $26.91
73600   26    Radex Ankle 2 Views                                              $8.11
73600   TC    Radex Ankle 2 Views                                             $18.80
73610         Radex Ankle Compl Minimum 3 Views                               $29.11
73610   26    Radex Ankle Compl Minimum 3 Views                                $8.84
73610   TC    Radex Ankle Compl Minimum 3 Views                               $20.27
73615         Radex Ankle Arthg Rs&I                                         $110.30
73615   26    Radex Ankle Arthg Rs&I                                          $28.40
73615   TC    Radex Ankle Arthg Rs&I                                          $81.90
73616         Radiologic Examination, Ankle, Arthrography; Complete Proced    $54.60
73616   TC    Radiologic Examination, Ankle, Arthrography; Complete Proced    $38.22
73620         Radex Foot 2 Views                                              $26.91
73620   26    Radex Foot 2 Views                                               $8.11
73620   TC    Radex Foot 2 Views                                              $18.80
73630         Radex Foot Compl Minimum 3 Views                                $29.11
73630   26    Radex Foot Compl Minimum 3 Views                                 $8.84
73630   TC    Radex Foot Compl Minimum 3 Views                                $20.27
73650         Radex Calcaneus Minimum 2 Views                                 $26.18
73650   26    Radex Calcaneus Minimum 2 Views                                  $8.11
73650   TC    Radex Calcaneus Minimum 2 Views                                 $18.07
73660         Radex Toe Minimum 2 Views                                       $22.51
73660   26    Radex Toe Minimum 2 Views                                        $6.64
73660   TC    Radex Toe Minimum 2 Views                                       $15.87
73700         Ct Lxtr C-Matrl                                                $247.94
73700   26    Ct Lxtr C-Matrl                                                 $55.64
73700   TC    Ct Lxtr C-Matrl                                                $192.30
73701         Ct Lxtr C+ Matrl                                               $288.79
73701   26    Ct Lxtr C+ Matrl                                                $58.94
73701   TC    Ct Lxtr C+ Matrl                                               $229.85
73702         Ct Lxtr C-/C+                                                  $350.52
73702   26    Ct Lxtr C-/C+                                                   $61.87
73702   TC    Ct Lxtr C-/C+                                                  $288.65
73706         Cta Lxtr C-/C+ Post-Pxessing                                   $513.98
73706   26    Cta Lxtr C-/C+ Post-Pxessing                                    $95.24
73706   TC    Cta Lxtr C-/C+ Post-Pxessing                                   $418.74
73718         Mri Lxtr Oth/Thn Jt C-Matrl                                    $494.82
73718   26    Mri Lxtr Oth/Thn Jt C-Matrl                                     $67.59
73718   TC    Mri Lxtr Oth/Thn Jt C-Matrl                                    $427.23
73719         Mri Img Lxtr Oth/Thn Jt C+ Matrl                               $594.01
73719   26    Mri Img Lxtr Oth/Thn Jt C+ Matrl                                $81.20

                                           Page 128
                         MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                         Amount
73719   TC    Mri Img Lxtr Oth/Thn Jt C+ Matrl                   $512.81
73720         Mri Lxtr Oth/Thn Jt C-/C+                         $1,056.63
73720   26    Mri Lxtr Oth/Thn Jt C-/C+                          $108.62
73720   TC    Mri Lxtr Oth/Thn Jt C-/C+                          $948.01
73721         Mri Any Jt Lxtr C-Matrl                            $494.82
73721   26    Mri Any Jt Lxtr C-Matrl                              $67.59
73721   TC    Mri Any Jt Lxtr C-Matrl                            $427.23
73722         Mri Any Jt Lxtr C+ Matrl                           $594.42
73722   26    Mri Any Jt Lxtr C+ Matrl                             $81.55
73722   TC    Mri Any Jt Lxtr C+ Matrl                           $512.87
73723         Mri Any Jt Lxtr C-/C+                             $1,055.81
73723   26    Mri Any Jt Lxtr C-/C+                              $107.90
73723   TC    Mri Any Jt Lxtr C-/C+                              $947.91
73725         Mra Lxtr C+-Matrl                                  $528.38
73725   26    Mra Lxtr C+-Matrl                                    $92.78
73725   TC    Mra Lxtr C+-Matrl                                  $435.60
74000         Radex Abd 1 Anteropost View                          $29.12
74000   26    Radex Abd 1 Anteropost View                           $9.22
74000   TC    Radex Abd 1 Anteropost View                          $19.90
74010         Radex Abd Anteropost&Addl Oblq&Cone Views            $34.36
74010   26    Radex Abd Anteropost&Addl Oblq&Cone Views            $11.82
74010   TC    Radex Abd Anteropost&Addl Oblq&Cone Views            $22.54
74020         Radex Abd Compl W/Dcbts&/Erc Views                   $38.04
74020   26    Radex Abd Compl W/Dcbts&/Erc Views                   $13.66
74020   TC    Radex Abd Compl W/Dcbts&/Erc Views                   $24.38
74022         Radex Abd Compl Aqt Abd W/S/E/D Views 1 View Ch      $45.43
74022   26    Radex Abd Compl Aqt Abd W/S/E/D Views 1 View Ch      $16.25
74022   TC    Radex Abd Compl Aqt Abd W/S/E/D Views 1 View Ch      $29.18
74150         Ct Abd C-Matrl                                     $280.37
74150   26    Ct Abd C-Matrl                                       $60.42
74150   TC    Ct Abd C-Matrl                                     $219.95
74160         Ct Abd C+ Matrl                                    $330.75
74160   26    Ct Abd C+ Matrl                                      $64.46
74160   TC    Ct Abd C+ Matrl                                    $266.29
74170         Ct Abd C-/C+                                       $400.17
74170   26    Ct Abd C-/C+                                         $70.67
74170   TC    Ct Abd C-/C+                                       $329.50
74175         Cta Abd C-/C+ Post-Pxessing                        $553.05
74175   26    Cta Abd C-/C+ Post-Pxessing                          $95.18
74175   TC    Cta Abd C-/C+ Post-Pxessing                        $457.87
74181         Mri Abd C-Matrl                                    $503.64
74181   26    Mri Abd C-Matrl                                      $73.88
74181   TC    Mri Abd C-Matrl                                    $429.76
74182         Mri Abd C+ Matrl                                   $601.65
74182   26    Mri Abd C+ Matrl                                     $86.76
74182   TC    Mri Abd C+ Matrl                                   $514.89
74183         Mri Abd C-/C+                                     $1,065.09
74183   26    Mri Abd C-/C+                                      $113.86
74183   TC    Mri Abd C-/C+                                      $951.23
74185         Mra Abd C+-Matrl                                   $527.27
74185   26    Mra Abd C+-Matrl                                     $91.69
74185   TC    Mra Abd C+-Matrl                                   $435.58
74190         Pritoneogram Rs&I                                    $75.26
74190   26    Pritoneogram Rs&I                                    $24.35
74190   TC    Pritoneogram Rs&I                                    $50.91

                                          Page 129
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                       Amount
74210         Radex Pharynx&/Crv Esoph                           $64.53
74210   26    Radex Pharynx&/Crv Esoph                           $18.44
74210   TC    Radex Pharynx&/Crv Esoph                           $46.09
74220         Radex Esoph                                        $69.36
74220   26    Radex Esoph                                        $23.24
74220   TC    Radex Esoph                                        $46.12
74230         Swlng Funcj W/Cineradiograpy/Vidradiograpy         $77.86
74230   26    Swlng Funcj W/Cineradiograpy/Vidradiograpy         $26.94
74230   TC    Swlng Funcj W/Cineradiograpy/Vidradiograpy         $50.92
74235         Rmvl Fb Esophgl W/Use Balo Cath Rs&I              $162.48
74235   26    Rmvl Fb Esophgl W/Use Balo Cath Rs&I               $60.56
74235   TC    Rmvl Fb Esophgl W/Use Balo Cath Rs&I              $101.92
74240         Radex Gi Trc Upr +-Dlyd Flms W/O Kub               $92.36
74240   26    Radex Gi Trc Upr +-Dlyd Flms W/O Kub               $35.47
74240   TC    Radex Gi Trc Upr +-Dlyd Flms W/O Kub               $56.89
74241         Radex Gi Trc Upr +-Dlyd Flms W/Kub                 $93.45
74241   26    Radex Gi Trc Upr +-Dlyd Flms W/Kub                 $35.45
74241   TC    Radex Gi Trc Upr +-Dlyd Flms W/Kub                 $58.00
74245         Radex Gi Trc Upr W/Sm Int W/Mlt Srl Flms          $139.53
74245   26    Radex Gi Trc Upr W/Sm Int W/Mlt Srl Flms           $46.51
74245   TC    Radex Gi Trc Upr W/Sm Int W/Mlt Srl Flms           $93.02
74246         Radex Gi Upr C+ +-Gluc/Dlyd Flms W/O Kub          $100.11
74246   26    Radex Gi Upr C+ +-Gluc/Dlyd Flms W/O Kub           $35.46
74246   TC    Radex Gi Upr C+ +-Gluc/Dlyd Flms W/O Kub           $64.65
74247         Radex Gi Upr C+ +-Gluc +-Dlyd Flms W/Kub          $101.98
74247   26    Radex Gi Upr C+ +-Gluc +-Dlyd Flms W/Kub           $35.47
74247   TC    Radex Gi Upr C+ +-Gluc +-Dlyd Flms W/Kub           $66.51
74249         Radex Gi Upr C+ +-Gluc W/Sm Int Follw-Thru        $147.24
74249   26    Radex Gi Upr C+ +-Gluc W/Sm Int Follw-Thru         $46.50
74249   TC    Radex Gi Upr C+ +-Gluc W/Sm Int Follw-Thru        $100.74
74250         Radex Sm Int W/Mlt Srl Flms                        $74.89
74250   26    Radex Sm Int W/Mlt Srl Flms                        $23.98
74250   TC    Radex Sm Int W/Mlt Srl Flms                        $50.91
74251         Radex Sm Int W/Mlt Srl Flms Via Enteroclss Tube    $86.47
74251   26    Radex Sm Int W/Mlt Srl Flms Via Enteroclss Tube    $35.48
74251   TC    Radex Sm Int W/Mlt Srl Flms Via Enteroclss Tube    $50.99
74260         Duodenograpy Hypotonic                             $83.35
74260   26    Duodenograpy Hypotonic                             $25.45
74260   TC    Duodenograpy Hypotonic                             $57.90
74270         Radex Colon Barium Enema +-Kub                    $102.71
74270   26    Radex Colon Barium Enema +-Kub                     $35.47
74270   TC    Radex Colon Barium Enema +-Kub                     $67.24
74280         Radex Colon C+ W/Spec Hi Dns Barium +-Gluc        $138.14
74280   26    Radex Colon C+ W/Spec Hi Dns Barium +-Gluc         $50.60
74280   TC    Radex Colon C+ W/Spec Hi Dns Barium +-Gluc         $87.54
74283         Ther Enema C+ Rdctj Intussusception/Obstrcj       $203.91
74283   26    Ther Enema C+ Rdctj Intussusception/Obstrcj       $103.26
74283   TC    Ther Enema C+ Rdctj Intussusception/Obstrcj       $100.65
74285         Rad Xm,Cln;Hgh Kil Tech Polyp Study               $100.10
74285   26    Rad Xm,Cln;Hgh Kil Tech Polyp Study                $30.03
74285   TC    Rad Xm,Cln;Hgh Kil Tech Polyp Study                $70.07
74290         Ccg Oral Cntrst                                    $45.43
74290   26    Ccg Oral Cntrst                                    $16.25
74290   TC    Ccg Oral Cntrst                                    $29.18
74291         Ccg Oral Cntrst Addl/Repeat Xm/Mlt D Xm            $26.22

                                            Page 130
                         MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
74291    26   Ccg Oral Cntrst Addl/Repeat Xm/Mlt D Xm                         $10.34
74291   TC    Ccg Oral Cntrst Addl/Repeat Xm/Mlt D Xm                         $15.88
74300         Cholangrph&/Pcg Intraop Rs&I                                    $18.58
74300   26    Cholangrph&/Pcg Intraop Rs&I                                    $18.64
74300   TC    Cholangrph&/Pcg Intraop Rs&I                                     $0.00
74301         Cholangrph&/Pcg Addl Set Intraop Rs&I                           $11.29
74301   26    Cholangrph&/Pcg Addl Set Intraop Rs&I                           $10.80
74301   TC    Cholangrph&/Pcg Addl Set Intraop Rs&I                            $0.00
74305         Cholangrph&/Pcg Thru Cath Rs&I                                  $52.49
74305   26    Cholangrph&/Pcg Thru Cath Rs&I                                  $21.44
74305   TC    Cholangrph&/Pcg Thru Cath Rs&I                                  $31.05
74310         Cholangiography And/Or Pancreatography                          $76.94
74315         Cholangiography And/Or Pancreatography                          $54.60
74320         Cholangrph Prq Transhepatc Rs&I                                $150.22
74320   26    Cholangrph Prq Transhepatc Rs&I                                 $27.25
74320   TC    Cholangrph Prq Transhepatc Rs&I                                $122.97
74321         Cholangiography, Percutaneous, Transhepatic; Complete Proced    $86.45
74321   TC    Cholangiography, Percutaneous, Transhepatic; Complete Proced    $60.52
74325         Diag Pneumopritoneum;Suprv & Interp Only                        $45.50
74325   TC    Diag Pneumopritoneum;Suprv & Interp Only                        $31.85
74326         Diag Pnmprtnevm;Complete Proc                                   $72.80
74326   TC    Diag Pnmprtnevm;Complete Proc                                   $50.96
74327         Po Biliary St1 Rmvl Prq Rs&I                                   $105.27
74327   26    Po Biliary St1 Rmvl Prq Rs&I                                    $35.83
74327   TC    Po Biliary St1 Rmvl Prq Rs&I                                    $69.44
74328         Ndsc Cathj Biliary Dux Sys Rs&I                                $158.84
74328   26    Ndsc Cathj Biliary Dux Sys Rs&I                                 $35.75
74328   TC    Ndsc Cathj Biliary Dux Sys Rs&I                                $123.09
74329         Ndsc Cathj Pncrtc Dux Sys Rs&I                                 $158.84
74329   26    Ndsc Cathj Pncrtc Dux Sys Rs&I                                  $35.75
74329   TC    Ndsc Cathj Pncrtc Dux Sys Rs&I                                 $123.09
74330         Cmbn Ndsc Cathj Biliary&Pncrtc Dux Syss Rs&I                   $169.27
74330   26    Cmbn Ndsc Cathj Biliary&Pncrtc Dux Syss Rs&I                    $46.09
74330   TC    Cmbn Ndsc Cathj Biliary&Pncrtc Dux Syss Rs&I                   $123.18
74340         Intro Long Gi Tube W/Mlt Fluor&Flms Rs&I                       $128.92
74340   26    Intro Long Gi Tube W/Mlt Fluor&Flms Rs&I                        $27.25
74340   TC    Intro Long Gi Tube W/Mlt Fluor&Flms Rs&I                       $101.67
74350         Prq Plmt Gastrostomy Tube Rs&I                                 $161.81
74350   26    Prq Plmt Gastrostomy Tube Rs&I                                  $38.71
74350   TC    Prq Plmt Gastrostomy Tube Rs&I                                 $123.11
74351         Percutaneous Placement Of Gastrostomy Tube; Complete Procedu   $350.94
74355         Prq Plmt Enteroclss Tube Rs&I                                  $140.50
74355   26    Prq Plmt Enteroclss Tube Rs&I                                   $38.72
74355   TC    Prq Plmt Enteroclss Tube Rs&I                                  $101.78
74356         Percutaneous Placement Of Enteroclysis Tube; Complete Proced   $350.94
74356   26    Percutaneous Placement Of Enteroclysis Tube; Complete Proced   $105.28
74360         Intral Dilat Strixs&/Obstrcjs Rs&I                             $150.59
74360   26    Intral Dilat Strixs&/Obstrcjs Rs&I                              $27.62
74360   TC    Intral Dilat Strixs&/Obstrcjs Rs&I                             $122.97
74361         Intraluminal Dilation Of Strictures And/Or Obstructions (Eg,   $365.37
74363         Prq Transhepatc Dilat Biliary Dux Strix Rs&I                   $282.39
74363   26    Prq Transhepatc Dilat Biliary Dux Strix Rs&I                    $44.93
74363   TC    Prq Transhepatc Dilat Biliary Dux Strix Rs&I                   $237.46
74400         Urograpy Plog Iv +-Kub +-Tomog                                  $91.14
74400   26    Urograpy Plog Iv +-Kub +-Tomog                                  $24.73

                                          Page 131
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
74400   TC    Urograpy Plog Iv +-Kub +-Tomog                                  $66.41
74405         Urography, Intravenous; With Special Hypertensive Contrast/C    $99.12
74405   26    Urography, Intravenous; With Special Hypertensive Contrast/C    $29.74
74405   TC    Urography, Intravenous; With Special Hypertensive Contrast/C    $69.38
74406         Radiation Treatment Delivery, Single Treatment Area 20Mev        $0.00
74406   26    Radiation Treatment Delivery, Single Treatment Area 20Mev        $0.00
74406   TC    Radiation Treatment Delivery, Single Treatment Area 20Mev        $0.00
74407         Radiation Treatment Delivery 2 Separate Treatment Areas Thr      $0.00
74407   26    Radiation Treatment Delivery 2 Separate Treatment Areas Thr      $0.00
74407   TC    Radiation Treatment Delivery 2 Separate Treatment Areas Thr      $0.00
74410         Urograpy Nfs Drip Tq&/Bolus Tq                                 $101.00
74410   26    Urograpy Nfs Drip Tq&/Bolus Tq                                  $24.69
74410   TC    Urograpy Nfs Drip Tq&/Bolus Tq                                  $76.31
74415         Urograpy Nfs Drip Tq&/Bolus Tq W/Nephrotomog                   $107.25
74415   26    Urograpy Nfs Drip Tq&/Bolus Tq W/Nephrotomog                    $24.69
74415   TC    Urograpy Nfs Drip Tq&/Bolus Tq W/Nephrotomog                    $82.56
74420         X-Ray, Urinary Tract Exam With Contrast Material               $120.01
74420   26    X-Ray, Urinary Tract Exam With Contrast Material                $18.41
74420   TC    X-Ray, Urinary Tract Exam With Contrast Material               $101.60
74425         Urograpy Antegrade Rs&I                                         $69.32
74425   26    Urograpy Antegrade Rs&I                                         $18.44
74425   TC    Urograpy Antegrade Rs&I                                         $50.88
74426         Urography, Antegrade, (Pyelostogram, Nephrostogram, Loopogra    $63.70
74426   TC    Urography, Antegrade, (Pyelostogram, Nephrostogram, Loopogra    $44.59
74430         Cstograpy Minimum 3 Views Rs&I                                  $57.93
74430   26    Cstograpy Minimum 3 Views Rs&I                                  $16.60
74430   TC    Cstograpy Minimum 3 Views Rs&I                                  $41.33
74431         Cystography, Minimum Of Three Views; Complete Procedure         $50.05
74431   26    Cystography, Minimum Of Three Views; Complete Procedure         $15.02
74431   TC    Cystography, Minimum Of Three Views; Complete Procedure         $35.04
74440         Vasograpy Vesiculograpy/Epididymograpy Rs&I                     $63.09
74440   26    Vasograpy Vesiculograpy/Epididymograpy Rs&I                     $19.19
74440   TC    Vasograpy Vesiculograpy/Epididymograpy Rs&I                     $43.90
74441         Vasography, Vesiculography, Or Epididymography; Complete Pro    $84.84
74441   TC    Vasography, Vesiculography, Or Epididymography; Complete Pro    $59.39
74445         C/P/A Cavernosograpy Rs&I                                      $102.22
74445   26    C/P/A Cavernosograpy Rs&I                                       $58.14
74445   TC    C/P/A Cavernosograpy Rs&I                                       $44.08
74446         Corpora Cavernosography; Complete Procedure                     $91.00
74446   TC    Corpora Cavernosography; Complete Procedure                     $63.70
74450         Urethrocstograpy Rtrgr Rs&I                                     $73.72
74450   26    Urethrocstograpy Rtrgr Rs&I                                     $16.96
74450   TC    Urethrocstograpy Rtrgr Rs&I                                     $56.76
74451         Urethrocystography, Retrograde; Complete Procedure              $81.54
74451   TC    Urethrocystography, Retrograde; Complete Procedure              $57.08
74455         Urethrocstograpy Voiding Rs&I                                   $78.92
74455   26    Urethrocstograpy Voiding Rs&I                                   $16.97
74455   TC    Urethrocstograpy Voiding Rs&I                                   $61.95
74456         Urethrocystography, Voiding; Complete Procedure                 $89.02
74456   TC    Urethrocystography, Voiding; Complete Procedure                 $62.31
74460         Pneumography Retrprtnl;Suprv & Interp Only                      $63.70
74461         Pneumgrphy Retrprtnl;Complete Procedure                        $109.20
74470         Radex Rnl Cst Std Translmbr C+ Rs&I                             $76.04
74470   26    Radex Rnl Cst Std Translmbr C+ Rs&I                             $27.31
74470   TC    Radex Rnl Cst Std Translmbr C+ Rs&I                             $48.73

                                           Page 132
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
74471         Radiologic Examination, Renal Cyst Study, Translumbar, Contr   $163.80
74471   TC    Radiologic Examination, Renal Cyst Study, Translumbar, Contr   $114.66
74475         Intro Cath In Rnl Pelvis Drg&/Njx Prq Rs&I                     $185.85
74475   26    Intro Cath In Rnl Pelvis Drg&/Njx Prq Rs&I                      $27.23
74475   TC    Intro Cath In Rnl Pelvis Drg&/Njx Prq Rs&I                     $158.62
74476         Introduction Of Intracatheter Or Catheter Into Renal Pelvis    $476.21
74476   TC    Introduction Of Intracatheter Or Catheter Into Renal Pelvis    $333.35
74480         Intro Urtrl Cath/Stent Prq Rs&I                                $185.85
74480   26    Intro Urtrl Cath/Stent Prq Rs&I                                 $27.23
74480   TC    Intro Urtrl Cath/Stent Prq Rs&I                                $158.62
74481         Introduction Of Ureteral Catheter Or Stent Into Ureter Throu   $546.25
74481   TC    Introduction Of Ureteral Catheter Or Stent Into Ureter Throu   $382.38
74485         Dilat Nfros Urtrs/Urt Rs&I                                     $151.04
74485   26    Dilat Nfros Urtrs/Urt Rs&I                                      $28.00
74485   TC    Dilat Nfros Urtrs/Urt Rs&I                                     $123.04
74486         Dilation Of Nephrostomy Or Ureters With Fluoroscopic Monitor   $436.36
74486   TC    Dilation Of Nephrostomy Or Ureters With Fluoroscopic Monitor   $305.45
74710         Pelvimetry +-Placental Loclzj                                   $58.67
74710   26    Pelvimetry +-Placental Loclzj                                   $17.34
74710   TC    Pelvimetry +-Placental Loclzj                                   $41.33
74720         Radiologic Examination, Abdomen, For Fetal Age, Fetal Positi     $0.00
74725         Radiologic Examination, Abdomen, For Fetal Age, Fetal Positi    $37.31
74730         Placentography With Contrast Cystography;                       $45.50
74731         Placentography With Contrast Cystography;                       $63.70
74740         Hsg Rs&I                                                        $70.43
74740   26    Hsg Rs&I                                                        $19.54
74740   TC    Hsg Rs&I                                                        $50.89
74741         Hysterosalpingography; Complete Procedure                       $91.00
74741   TC    Hysterosalpingography; Complete Procedure                       $63.70
74742         Transcrv Cathj Flp Tube Rs&I                                   $153.57
74742   26    Transcrv Cathj Flp Tube Rs&I                                    $30.56
74742   TC    Transcrv Cathj Flp Tube Rs&I                                   $123.01
74760         Pneumography Pelvic;Suprv & Interp Only                         $54.60
74761         Pneumogrphy,Pelvic;Complete Proc                                $91.00
74770         Radiologic Examination, Fetal Study, Intrauterine Contrast      $81.90
74771         Radiologic Examination, Fetal Study, Intrauterine Contrast     $127.40
74775         Prineogram                                                      $89.01
74775   26    Prineogram                                                      $32.13
74775   TC    Prineogram                                                      $56.88
75500         Angiocardiography By Cineradiography, Radiological Supervisi   $438.51
75500   26    Angiocardiography By Cineradiography, Radiological Supervisi   $131.55
75500   TC    Angiocardiography By Cineradiography, Radiological Supervisi   $306.96
75501         Angiocardiography By Cineradiography; Complete Procedure (In   $300.30
75501   TC    Angiocardiography By Cineradiography; Complete Procedure (In   $210.21
75505         Angiocardiography By Serialography, Single Plane, Radiologic   $438.51
75505   26    Angiocardiography By Serialography, Single Plane, Radiologic   $131.55
75505   TC    Angiocardiography By Serialography, Single Plane, Radiologic   $306.96
75506         Angiocardiography By Serialography, Single Plane; Complete P   $236.60
75506   TC    Angiocardiography By Serialography, Single Plane; Complete P   $165.62
75507         Angiocardiography By Serialography, Multi-Plane, Radiologica   $446.88
75507   26    Angiocardiography By Serialography, Multi-Plane, Radiologica   $134.06
75507   TC    Angiocardiography By Serialography, Multi-Plane, Radiologica   $312.82
75509         Angiocardiography By Serialography, Multi-Plane; Complete Pr   $236.60
75509   TC    Angiocardiography By Serialography, Multi-Plane; Complete Pr   $165.62
75510         Angcrdgrphy C02 Pstve Cntrst Intrvns Prcrdl Effsn              $109.20

                                           Page 133
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
75511         Angcrd Grphy C02 Intrvns Prcrdleffsn Atrl Thcknss              $136.50
75519         Cardiac Radiography, Selective Cardiac Catheterization, Righ   $423.62
75519   26    Cardiac Radiography, Selective Cardiac Catheterization, Righ   $127.09
75519   TC    Cardiac Radiography, Selective Cardiac Catheterization, Righ   $296.53
75520         Cardiac Radiography, Selective Cardiac Catheterization, Righ   $546.00
75520   TC    Cardiac Radiography, Selective Cardiac Catheterization, Righ   $382.20
75523         Cardiac Radiography, Selective Cardiac Catheterization, Left   $423.62
75523   26    Cardiac Radiography, Selective Cardiac Catheterization, Left   $127.09
75524         Cardiac Radiography, Selective Cardiac Catheterization, Left   $546.00
75524   TC    Cardiac Radiography, Selective Cardiac Catheterization, Left   $382.20
75527         Cardiac Radiography, Selective Cardiac Catheterization, Righ   $456.18
75527   26    Cardiac Radiography, Selective Cardiac Catheterization, Righ   $136.85
75527   TC    Cardiac Radiography, Selective Cardiac Catheterization, Righ   $319.33
75528         Cardiac Radiography, Selective Cardiac Catheterization, Righ   $627.90
75528   TC    Cardiac Radiography, Selective Cardiac Catheterization, Righ   $439.53
75552         Car Mri Morphology C-Matrl                                     $516.80
75552   26    Car Mri Morphology C-Matrl                                      $81.34
75552   TC    Car Mri Morphology C-Matrl                                     $435.46
75553         Car Mri Morphology C+ Matrl                                    $537.34
75553   26    Car Mri Morphology C+ Matrl                                    $101.66
75553   TC    Car Mri Morphology C+ Matrl                                    $435.68
75554         Car Mri Funcj +-Morphology Compl Std                           $529.40
75554   26    Car Mri Funcj +-Morphology Compl Std                            $93.86
75554   TC    Car Mri Funcj +-Morphology Compl Std                           $435.54
75555         Car Mri Funcj +-Morphology Lmtd Std                            $526.04
75555   26    Car Mri Funcj +-Morphology Lmtd Std                             $90.53
75555   TC    Car Mri Funcj +-Morphology Lmtd Std                            $435.51
75556         Car Mri Vel Flo Mapg                                             $0.00
75600         Aortograpy Thrc W/O Srlograpy Rs&I                             $514.06
75600   26    Aortograpy Thrc W/O Srlograpy Rs&I                              $25.70
75600   TC    Aortograpy Thrc W/O Srlograpy Rs&I                             $488.36
75601         Aortography, Thoracic, Without Serialography; Complete Proce   $273.00
75601   TC    Aortography, Thoracic, Without Serialography; Complete Proce   $191.10
75605         Aortograpy Thrc Srlograpy Rs&I                                 $547.26
75605   26    Aortograpy Thrc Srlograpy Rs&I                                  $58.50
75605   TC    Aortograpy Thrc Srlograpy Rs&I                                 $488.76
75606         Aortography, Thoracic, By Serialography; Complete Procedure    $236.60
75606   TC    Aortography, Thoracic, By Serialography; Complete Procedure    $165.62
75620         Aortography, Abdominal, Translumbar, Without Serialography     $136.50
75621         Aortography, Abdominal, Translumbar, Without Serialography     $163.80
75622         Aortography, Abdominal, Catheter, Without Serialography        $218.40
75623         Aortography, Abdominal, Catheter, Without Serialography        $300.30
75625         Aortograpy Abdl Srlograpy Rs&I                                 $546.90
75625   26    Aortograpy Abdl Srlograpy Rs&I                                  $58.14
75625   TC    Aortograpy Abdl Srlograpy Rs&I                                 $488.76
75626         Aortography, Abdominal, Translumbar, By Serialography; Compl   $309.40
75626   TC    Aortography, Abdominal, Translumbar, By Serialography; Compl   $216.58
75627         Aortography, Abdominal, Catheter, By Serialography; Supervis   $273.00
75628         Aortography, Abdominal, Catheter, By Serialography; Complete   $382.20
75628   26    Aortography, Abdominal, Catheter, By Serialography; Complete   $114.66
75628   TC    Aortography, Abdominal, Catheter, By Serialography; Complete   $267.54
75630         Aortograpy Abdl Bi Iliofem Lxtr Cath Rs&I                      $602.18
75630   26    Aortograpy Abdl Bi Iliofem Lxtr Cath Rs&I                       $92.01
75630   TC    Aortograpy Abdl Bi Iliofem Lxtr Cath Rs&I                      $510.17
75631         Aortography, Abdominal Plus Bilateral Iliofemoral Lower Extr   $682.50

                                           Page 134
                           MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
75631   TC    Aortography, Abdominal Plus Bilateral Iliofemoral Lower Extr   $477.75
75635         Cta Aa&Bi Iliofem Lxtr Rs&I C-/C+ Post-Pxessing                $722.33
75635   26    Cta Aa&Bi Iliofem Lxtr Rs&I C-/C+ Post-Pxessing                $121.57
75635   TC    Cta Aa&Bi Iliofem Lxtr Rs&I C-/C+ Post-Pxessing                $600.76
75650         Angrph Cervicocere Cath W/Vsl Origin Rs&I                      $564.80
75650   26    Angrph Cervicocere Cath W/Vsl Origin Rs&I                       $75.80
75650   TC    Angrph Cervicocere Cath W/Vsl Origin Rs&I                      $489.00
75651         Angiography, Cervicocerebral, Catheter, Including Vessel Ori   $382.20
75651   TC    Angiography, Cervicocerebral, Catheter, Including Vessel Ori   $267.54
75652         Angiography, Cervicocerebral, Selective Catheter, Including    $609.70
75653         Angiography, Cervicocerebral, Selective Catheter, Including    $282.10
75653   TC    Angiography, Cervicocerebral, Selective Catheter, Including    $197.47
75654         Angiography, Cervicocerebral, Selective Catheter, Including    $182.00
75655         Angiography, Cervicocerebral, Selective Catheter, Including    $373.10
75655   TC    Angiography, Cervicocerebral, Selective Catheter, Including    $261.17
75656         Angiography, Cervicocerebral, Selective Catheter, Including    $273.00
75657         Angiography, Cervicocerebral, Selective Catheter, Including    $464.10
75657   TC    Angiography, Cervicocerebral, Selective Catheter, Including    $324.87
75658         Angrph Brach Rtrgr Rs&I                                        $556.94
75658   26    Angrph Brach Rtrgr Rs&I                                         $68.06
75658   TC    Angrph Brach Rtrgr Rs&I                                        $488.88
75659         Angiography, Brachial, Retrograde; Complete Procedure          $436.80
75659   TC    Angiography, Brachial, Retrograde; Complete Procedure          $305.76
75660         Angrph Xtrnl Crtd Uni Slctv Rs&I                               $555.84
75660   26    Angrph Xtrnl Crtd Uni Slctv Rs&I                                $66.98
75660   TC    Angrph Xtrnl Crtd Uni Slctv Rs&I                               $488.86
75661         Angiography, External Carotid, Cerebral, Unilateral, Selecti   $382.20
75661   TC    Angiography, External Carotid, Cerebral, Unilateral, Selecti   $267.54
75662         Angrph Xtrnl Crtd Bi Slctv Rs&I                                $575.61
75662   26    Angrph Xtrnl Crtd Bi Slctv Rs&I                                 $86.51
75662   TC    Angrph Xtrnl Crtd Bi Slctv Rs&I                                $489.10
75663         Angiography, External Carotid, Cerebral, Bilateral, Selectiv   $464.10
75663   TC    Angiography, External Carotid, Cerebral, Bilateral, Selectiv   $324.87
75665         Angrph Crtd Cere Uni Rs&I                                      $555.89
75665   26    Angrph Crtd Cere Uni Rs&I                                       $66.98
75665   TC    Angrph Crtd Cere Uni Rs&I                                      $488.91
75667         Angiography, Carotid, Cerebral, Unilateral; Direct Puncture,   $218.40
75667   TC    Angiography, Carotid, Cerebral, Unilateral; Direct Puncture,   $152.88
75669         Angiography, Carotid, Cerebral, Unilateral; Catheter, Comple   $245.70
75669   TC    Angiography, Carotid, Cerebral, Unilateral; Catheter, Comple   $171.99
75671         Angrph Crtd Cere Bi Rs&I                                       $574.15
75671   26    Angrph Crtd Cere Bi Rs&I                                        $85.03
75671   TC    Angrph Crtd Cere Bi Rs&I                                       $489.12
75672         Angiography, Carotid, Cerebral, Bilateral; Direct Puncture,    $300.30
75672   TC    Angiography, Carotid, Cerebral, Bilateral; Direct Puncture,    $210.21
75673         Angiography, Carotid, Cerebral, Bilateral; Catheter, Complet   $327.60
75673   TC    Angiography, Carotid, Cerebral, Bilateral; Catheter, Complet   $229.32
75676         Angrph Crtd Crv Uni Rs&I                                       $556.25
75676   26    Angrph Crtd Crv Uni Rs&I                                        $67.31
75676   TC    Angrph Crtd Crv Uni Rs&I                                       $488.94
75677         Angiography, Carotid, Cervical, Unilateral; Direct Puncture,   $218.40
75677   TC    Angiography, Carotid, Cervical, Unilateral; Direct Puncture,   $152.88
75678         Angiography, Carotid, Cervical, Unilateral; Catheter, Comple   $245.70
75678   TC    Angiography, Carotid, Cervical, Unilateral; Catheter, Comple   $171.99
75680         Angrph Crtd Crv Bi Rs&I                                        $574.15

                                             Page 135
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
75680    26   Angrph Crtd Crv Bi Rs&I                                         $85.03
75680   TC    Angrph Crtd Crv Bi Rs&I                                        $489.12
75681         Angiography, Carotid, Cervical, Bilateral; Direct Puncture,    $300.30
75681   TC    Angiography, Carotid, Cervical, Bilateral; Direct Puncture,    $210.21
75682         Angiography, Carotid, Cervical, Bilateral; Catheter, Complet   $354.90
75682   TC    Angiography, Carotid, Cervical, Bilateral; Catheter, Complet   $248.43
75685         Angrph Vrt Crv&/Icra Rs&I                                      $555.48
75685   26    Angrph Vrt Crv&/Icra Rs&I                                       $66.60
75685   TC    Angrph Vrt Crv&/Icra Rs&I                                      $488.88
75686         Angiography, Vertebral Direct Puncture, Complete Procedure     $300.30
75686   TC    Angiography, Vertebral Direct Puncture, Complete Procedure     $210.21
75687         Angiography, Vertebral; Catheter, Complete Procedure           $245.70
75687   TC    Angiography, Vertebral; Catheter, Complete Procedure           $171.99
75690         Angiography, Vertebral, Cervical, Unilateral; Supervision An   $136.50
75691         Angiography, Vertebral, Cervical, Unilateral;                  $273.00
75692         Angiography, Vertebral, Cervical, Unilateral; Catheter, Comp   $300.30
75692   TC    Angiography, Vertebral, Cervical, Unilateral; Catheter, Comp   $210.21
75695         Angiography, Vertebral, Cervical, Bilateral; Supervision And   $163.00
75696         Angiography, Vertebral, Cervical, Bilateral;                   $327.60
75697         Angiography, Vertebral, Cervical, Bilateral; Catheter, Compl   $354.90
75697   TC    Angiography, Vertebral, Cervical, Bilateral; Catheter, Compl   $248.43
75705         Angrph Spi Slctv Rs&I                                          $601.36
75705   26    Angrph Spi Slctv Rs&I                                          $111.97
75705   TC    Angrph Spi Slctv Rs&I                                          $489.39
75706         Angiography, Spinal, Selective; Complete Procedure             $300.30
75706   TC    Angiography, Spinal, Selective; Complete Procedure             $210.21
75710         Angrph Xtr Uni Rs&I                                            $547.31
75710   26    Angrph Xtr Uni Rs&I                                             $58.51
75710   TC    Angrph Xtr Uni Rs&I                                            $488.80
75711         Angiography, Extremity, Unilateral; Without Serialography, C   $163.80
75711   TC    Angiography, Extremity, Unilateral; Without Serialography, C   $114.66
75712         Angiography, Extremity, Unilateral; By Serialography, Comple   $191.10
75712   TC    Angiography, Extremity, Unilateral; By Serialography, Comple   $133.77
75716         Angrph Xtr Bi Rs&I                                             $555.48
75716   26    Angrph Xtr Bi Rs&I                                              $66.60
75716   TC    Angrph Xtr Bi Rs&I                                             $488.88
75717         Angiography, Extremity, Bilateral; Without Serialography, Co   $239.76
75717   TC    Angiography, Extremity, Bilateral; Without Serialography, Co   $167.83
75718         Angiography, Extremity, Bilateral; By Serialography, Complet   $998.85
75718   TC    Angiography, Extremity, Bilateral; By Serialography, Complet   $699.20
75722         Angrph Rnl Uni Slctv W/Flush Aortogram Rs&I                    $547.63
75722   26    Angrph Rnl Uni Slctv W/Flush Aortogram Rs&I                     $58.87
75722   TC    Angrph Rnl Uni Slctv W/Flush Aortogram Rs&I                    $488.76
75723         Angiography, Renal, Unilateral, Selective (Including Flush A   $327.60
75723   TC    Angiography, Renal, Unilateral, Selective (Including Flush A   $229.32
75724         Angrph Rnl Bi Slctv W/Flush Aortogram Rs&I                     $566.54
75724   26    Angrph Rnl Bi Slctv W/Flush Aortogram Rs&I                      $77.62
75724   TC    Angrph Rnl Bi Slctv W/Flush Aortogram Rs&I                     $488.92
75725         Angiography, Renal, Bilateral, Selective (Including Flush Ao   $382.20
75725   TC    Angiography, Renal, Bilateral, Selective (Including Flush Ao   $267.54
75726         Angrph Visc Slctv/Supraslctv Rs&I                              $546.53
75726   26    Angrph Visc Slctv/Supraslctv Rs&I                               $57.77
75726   TC    Angrph Visc Slctv/Supraslctv Rs&I                              $488.76
75727         Angiography, Visceral; Selective (With Or Without Flush Aort   $382.20
75727   TC    Angiography, Visceral; Selective (With Or Without Flush Aort   $267.54

                                             Page 136
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
75728         Angiography, Visceral; Supraselective, Complete Procedure      $409.50
75728   TC    Angiography, Visceral; Supraselective, Complete Procedure      $286.65
75731         Angrph Adrnl Uni Slctv Rs&I                                    $546.53
75731   26    Angrph Adrnl Uni Slctv Rs&I                                     $57.77
75731   TC    Angrph Adrnl Uni Slctv Rs&I                                    $488.76
75732         Angiography, Adrenal, Unilateral, Selective; Complete Proced   $354.90
75732   TC    Angiography, Adrenal, Unilateral, Selective; Complete Proced   $248.43
75733         Angrph Adrnl Bi Slctv Rs&I                                     $555.48
75733   26    Angrph Adrnl Bi Slctv Rs&I                                      $66.60
75733   TC    Angrph Adrnl Bi Slctv Rs&I                                     $488.88
75734         Angiography, Adrenal, Bilateral, Selective; Complete Procedu   $409.50
75734   TC    Angiography, Adrenal, Bilateral, Selective; Complete Procedu   $286.65
75736         Angrph Pel Slctv/Supraslctv Rs&I                               $546.53
75736   26    Angrph Pel Slctv/Supraslctv Rs&I                                $57.77
75736   TC    Angrph Pel Slctv/Supraslctv Rs&I                               $488.76
75737         Angiography, Pelvic; Selective, Complete Procedure             $245.70
75737   TC    Angiography, Pelvic; Selective, Complete Procedure             $171.99
75738         Angiography, Pelvic; Supraselective, Complete Procedure        $273.00
75738   TC    Angiography, Pelvic; Supraselective, Complete Procedure        $191.10
75741         Angrph Pulm Uni Slctv Rs&I                                     $555.48
75741   26    Angrph Pulm Uni Slctv Rs&I                                      $66.60
75741   TC    Angrph Pulm Uni Slctv Rs&I                                     $488.88
75742         Angiography, Pulmonary, Unilateral, Selective; Complete Proc   $273.00
75742   TC    Angiography, Pulmonary, Unilateral, Selective; Complete Proc   $191.10
75743         Angrph Pulm Bi Slctv Rs&I                                      $572.97
75743   26    Angrph Pulm Bi Slctv Rs&I                                       $83.88
75743   TC    Angrph Pulm Bi Slctv Rs&I                                      $489.09
75744         Angiography, Pulmonary, Bilateral, Selective; Complete Proce   $327.60
75744   TC    Angiography, Pulmonary, Bilateral, Selective; Complete Proce   $229.32
75746         Angrph Pulm Nonslctv Cath/Ven Njx Rs&I                         $546.53
75746   26    Angrph Pulm Nonslctv Cath/Ven Njx Rs&I                          $57.77
75746   TC    Angrph Pulm Nonslctv Cath/Ven Njx Rs&I                         $488.76
75747         Angiography, Pulmonary; Catheter, Nonselective, Complete Pro   $354.90
75747   TC    Angiography, Pulmonary; Catheter, Nonselective, Complete Pro   $248.43
75748         Angiography, Pulmonary; Venous Injection, Complete Procedure   $218.40
75748   TC    Angiography, Pulmonary; Venous Injection, Complete Procedure   $152.88
75750         Angiography, Coronary, Root Injection, Radiological Supervis   $473.24
75750   26    Angiography, Coronary, Root Injection, Radiological Supervis   $141.97
75750   TC    Angiography, Coronary, Root Injection, Radiological Supervis   $331.27
75751         Angiography, Coronary, Root Injection; Complete Procedure      $300.30
75751   TC    Angiography, Coronary, Root Injection; Complete Procedure      $210.21
75752         Angiography, Coronary, Unilateral Selective Injection, Inclu   $473.24
75752   26    Angiography, Coronary, Unilateral Selective Injection, Inclu   $141.97
75752   TC    Angiography, Coronary, Unilateral Selective Injection, Inclu   $331.27
75753         Angiography, Coronary, Unilateral Selective Injection, Inclu   $491.40
75753   TC    Angiography, Coronary, Unilateral Selective Injection, Inclu   $343.98
75754         Angiography, Coronary, Bilateral Selective Injection, Includ   $481.92
75754   26    Angiography, Coronary, Bilateral Selective Injection, Includ   $144.58
75754   TC    Angiography, Coronary, Bilateral Selective Injection, Includ   $337.34
75755         Angiography, Coronary, Bilateral Selective Injection, Includ   $627.90
75755   TC    Angiography, Coronary, Bilateral Selective Injection, Includ   $439.53
75756         Angrph Int Mam Rs&I                                            $548.68
75756   26    Angrph Int Mam Rs&I                                             $59.92
75756   TC    Angrph Int Mam Rs&I                                            $488.76
75757         Angiography, Internal Mammary; Complete Procedure              $236.60

                                           Page 137
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
75757   TC    Angiography, Internal Mammary; Complete Procedure              $165.62
75762         Angiography, Coronary Bypass, Unilateral Selective Injection   $473.24
75762   26    Angiography, Coronary Bypass, Unilateral Selective Injection   $141.97
75762   TC    Angiography, Coronary Bypass, Unilateral Selective Injection   $331.27
75764         Angiography, Coronary Bypass, Unilateral Selective Injection   $491.40
75764   TC    Angiography, Coronary Bypass, Unilateral Selective Injection   $343.98
75766         Angiography, Coronary Bypass, Multiple Selective Injection,    $481.61
75766   26    Angiography, Coronary Bypass, Multiple Selective Injection,    $144.48
75766   TC    Angiography, Coronary Bypass, Multiple Selective Injection,    $337.13
75767         Angiography, Coronary Bypass, Multiple Selective Injection;    $627.00
75767   TC    Angiography, Coronary Bypass, Multiple Selective Injection;    $438.90
75774         Angrph Slctv Ea Vsl Studied After Basic Xm Rs&I                $507.02
75774   26    Angrph Slctv Ea Vsl Studied After Basic Xm Rs&I                 $18.76
75774   TC    Angrph Slctv Ea Vsl Studied After Basic Xm Rs&I                $488.26
75775         Angiography, Selective, Each Additional Vessel Studied After   $135.11
75775   TC    Angiography, Selective, Each Additional Vessel Studied After    $94.58
75790         Angrph Arven Shunt Rs&I                                        $148.00
75790   26    Angrph Arven Shunt Rs&I                                         $94.59
75790   TC    Angrph Arven Shunt Rs&I                                         $53.41
75801         Lymphangrph Xtr Only Uni Rs&I                                  $252.99
75801   26    Lymphangrph Xtr Only Uni Rs&I                                   $41.97
75801   TC    Lymphangrph Xtr Only Uni Rs&I                                  $211.02
75802         Lymphangiography, Extremity Only, Unilateral; Complete Proce   $245.70
75802   TC    Lymphangiography, Extremity Only, Unilateral; Complete Proce   $171.99
75803         Lymphangrph Xtr Only Bi Rs&I                                   $270.45
75803   26    Lymphangrph Xtr Only Bi Rs&I                                    $59.31
75803   TC    Lymphangrph Xtr Only Bi Rs&I                                   $211.14
75804         Lymphangiography, Extremity Only, Bilateral; Complete Proced   $273.00
75804   TC    Lymphangiography, Extremity Only, Bilateral; Complete Proced   $191.10
75805         Lymphangrph Pel/Abdl Uni Rs&I                                  $279.05
75805   26    Lymphangrph Pel/Abdl Uni Rs&I                                   $41.61
75805   TC    Lymphangrph Pel/Abdl Uni Rs&I                                  $237.44
75806         Lymphangiography, Pelvic/Abdominal, Unilateral; Complete Pro   $245.70
75806   TC    Lymphangiography, Pelvic/Abdominal, Unilateral; Complete Pro   $171.99
75807         Lymphangrph Pel/Abdl Bi Rs&I                                   $296.91
75807   26    Lymphangrph Pel/Abdl Bi Rs&I                                    $59.32
75807   TC    Lymphangrph Pel/Abdl Bi Rs&I                                   $237.59
75808         Lymphangiography, Pelvic/Abdominal, Bilateral; Complete Proc   $273.00
75808   TC    Lymphangiography, Pelvic/Abdominal, Bilateral; Complete Proc   $191.10
75809         Shuntogram Ndwellg Nonvasc Shunt Rs&I                           $55.09
75809   26    Shuntogram Ndwellg Nonvasc Shunt Rs&I                           $24.03
75809   TC    Shuntogram Ndwellg Nonvasc Shunt Rs&I                           $31.06
75810         Splenoportograpy Rs&I                                          $546.94
75810   26    Splenoportograpy Rs&I                                           $58.14
75810   TC    Splenoportograpy Rs&I                                          $488.80
75811         Splenoportography; Complete Procedure                          $245.70
75811   TC    Splenoportography; Complete Procedure                          $171.99
75820         Vngrph Xtr Uni Rs&I                                             $73.29
75820   26    Vngrph Xtr Uni Rs&I                                             $35.90
75820   TC    Vngrph Xtr Uni Rs&I                                             $37.39
75821         Venography, Extremity, Unilateral; Complete Procedure          $118.30
75821   TC    Venography, Extremity, Unilateral; Complete Procedure           $82.81
75822         Vngrph Xtr Bi Rs&I                                             $112.10
75822   26    Vngrph Xtr Bi Rs&I                                              $54.38
75822   TC    Vngrph Xtr Bi Rs&I                                              $57.72

                                            Page 138
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
75823         Venography, Extremity, Bilateral; Complete Procedure           $150.15
75823   TC    Venography, Extremity, Bilateral; Complete Procedure           $105.11
75825         Vngrph Caval Inf Srlograpy Rs&I                                $546.94
75825   26    Vngrph Caval Inf Srlograpy Rs&I                                 $58.14
75825   TC    Vngrph Caval Inf Srlograpy Rs&I                                $488.80
75826         Venography, Caval, Inferior, With Serialography; Complete Pr   $163.80
75826   TC    Venography, Caval, Inferior, With Serialography; Complete Pr   $114.66
75827         Vngrph Caval Suprior Srlograpy Rs&I                            $546.53
75827   26    Vngrph Caval Suprior Srlograpy Rs&I                             $57.77
75827   TC    Vngrph Caval Suprior Srlograpy Rs&I                            $488.76
75828         Venography, Caval, Superior, With Serialography; Complete Pr   $163.80
75828   TC    Venography, Caval, Superior, With Serialography; Complete Pr   $114.66
75831         Vngrph Rnl Uni Slctv Rs&I                                      $546.53
75831   26    Vngrph Rnl Uni Slctv Rs&I                                       $57.77
75831   TC    Vngrph Rnl Uni Slctv Rs&I                                      $488.76
75832         Venography, Renal, Unilateral, Selective; Complete Procedure   $191.10
75832   TC    Venography, Renal, Unilateral, Selective; Complete Procedure   $133.77
75833         Vngrph Rnl Bi Slctv Rs&I                                       $564.80
75833   26    Vngrph Rnl Bi Slctv Rs&I                                        $75.80
75833   TC    Vngrph Rnl Bi Slctv Rs&I                                       $489.00
75834         Venography, Renal, Bilateral, Selective; Complete Procedure    $245.70
75834   TC    Venography, Renal, Bilateral, Selective; Complete Procedure    $171.99
75840         Vngrph Adrnl Uni Slctv Rs&I                                    $547.35
75840   26    Vngrph Adrnl Uni Slctv Rs&I                                     $58.51
75840   TC    Vngrph Adrnl Uni Slctv Rs&I                                    $488.84
75841         Venography, Adrenal, Unilateral, Selective; Complete Procedu   $218.40
75841   TC    Venography, Adrenal, Unilateral, Selective; Complete Procedu   $152.88
75842         Vngrph Adrnl Bi Slctv Rs&I                                     $564.43
75842   26    Vngrph Adrnl Bi Slctv Rs&I                                      $75.41
75842   TC    Vngrph Adrnl Bi Slctv Rs&I                                     $489.02
75843         Venography, Adrenal, Bilateral, Selective; Complete Procedur   $327.60
75843   TC    Venography, Adrenal, Bilateral, Selective; Complete Procedur   $229.32
75845         Venography, Azygos                                             $109.20
75846         Venography, Azygos                                             $218.40
75847         Venography, Azygos                                             $191.10
75850         Venography, Intraosseous                                       $105.80
75851         Venography, Intraosseous                                       $163.80
75860         Vngrph Ven Sinus/Jug Cath Rs&I                                 $547.67
75860   26    Vngrph Ven Sinus/Jug Cath Rs&I                                  $58.87
75860   TC    Vngrph Ven Sinus/Jug Cath Rs&I                                 $488.80
75861         Venography, Sinus Or Jugular, Catheter; Complete Procedure     $263.90
75861   TC    Venography, Sinus Or Jugular, Catheter; Complete Procedure     $184.73
75870         Vngrph Suprior Sgtl Sinus Rs&I                                 $547.67
75870   26    Vngrph Suprior Sgtl Sinus Rs&I                                  $58.87
75870   TC    Vngrph Suprior Sgtl Sinus Rs&I                                 $488.80
75871         Venography, Superior Sagittal Sinus; Complete Procedure, Inc   $218.40
75871   TC    Venography, Superior Sagittal Sinus; Complete Procedure, Inc   $152.88
75872         Vngrph Edrl Rs&I                                               $546.53
75872   26    Vngrph Edrl Rs&I                                                $57.77
75872   TC    Vngrph Edrl Rs&I                                               $488.76
75873         Venography, Epidural; Complete Procedure                       $163.80
75873   TC    Venography, Epidural; Complete Procedure                       $114.66
75880         Vngrph Orb Rs&I                                                 $73.29
75880   26    Vngrph Orb Rs&I                                                 $35.90
75880   TC    Vngrph Orb Rs&I                                                 $37.39

                                            Page 139
                         MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
75881         Venography, Orbital; Complete Procedure                         $138.66
75881   TC    Venography, Orbital; Complete Procedure                           $97.06
75885         Prq Transhepatc Portograpy Hemodyn Eval Rs&I                    $561.79
75885   26    Prq Transhepatc Portograpy Hemodyn Eval Rs&I                      $72.86
75885   TC    Prq Transhepatc Portograpy Hemodyn Eval Rs&I                    $488.93
75886         Percutaneous Transhepatic Portography With Hemodynamic Evalu   $1,122.56
75886   TC    Percutaneous Transhepatic Portography With Hemodynamic Evalu    $785.79
75887         Prq Transhepatc Portograpy W/O Hemodyn Eval Rs&I                $561.79
75887   26    Prq Transhepatc Portograpy W/O Hemodyn Eval Rs&I                  $72.86
75887   TC    Prq Transhepatc Portograpy W/O Hemodyn Eval Rs&I                $488.93
75888         Percutaneous Transhepatic Portography Without Hemodynamic Ev   $1,122.56
75888   TC    Percutaneous Transhepatic Portography Without Hemodynamic Ev    $785.79
75889         Hepatc Vngrph Wdg/Fr Hemodyn Eval Rs&I                          $546.53
75889   26    Hepatc Vngrph Wdg/Fr Hemodyn Eval Rs&I                            $57.77
75889   TC    Hepatc Vngrph Wdg/Fr Hemodyn Eval Rs&I                          $488.76
75890         Hepatic Venography Wedged Or Free, With Hemodynamic Evaluati      $54.60
75890   TC    Hepatic Venography Wedged Or Free, With Hemodynamic Evaluati      $38.22
75891         Hepatc Vngrph Wdg/Fr W/O Hemodyn Eval Rs&I                       $546.53
75891   26    Hepatc Vngrph Wdg/Fr W/O Hemodyn Eval Rs&I                        $57.77
75891   TC    Hepatc Vngrph Wdg/Fr W/O Hemodyn Eval Rs&I                       $488.76
75892         Hepatic Venography, Wedged Or Free, Without Hemodynamic Eval   $1,029.24
75892   TC    Hepatic Venography, Wedged Or Free, Without Hemodynamic Eval    $720.47
75893         Ven Sampling Thru Cath +-Angrph Rs&I                            $515.56
75893   26    Ven Sampling Thru Cath +-Angrph Rs&I                              $27.17
75893   TC    Ven Sampling Thru Cath +-Angrph Rs&I                            $488.39
75894         Tcat Ther Embolization Any Meth Rs&I                           $1,003.97
75894   26    Tcat Ther Embolization Any Meth Rs&I                              $66.86
75894   TC    Tcat Ther Embolization Any Meth Rs&I                            $937.11
75895         Transcatheter Therapy, Embolization (Eg, Particulate Or Liqu    $325.78
75895   TC    Transcatheter Therapy, Embolization (Eg, Particulate Or Liqu    $228.05
75896         Tcat Ther Nfs Any Meth Rs&I                                      $881.99
75896   26    Tcat Ther Nfs Any Meth Rs&I                                       $67.30
75896   TC    Tcat Ther Nfs Any Meth Rs&I                                      $814.69
75897         Transcatheter Therapy, Infusion (Eg, Thrombolysis Other Than    $325.78
75897   TC    Transcatheter Therapy, Infusion (Eg, Thrombolysis Other Than    $228.05
75898         Angrph Cath F-Up Std Tcat Ther Embolization/Nfs                 $126.10
75898   26    Angrph Cath F-Up Std Tcat Ther Embolization/Nfs                   $84.56
75898   TC    Angrph Cath F-Up Std Tcat Ther Embolization/Nfs                   $41.54
75900         Exchng Cath Thrombolytic Ther C+ Mntr Rs&I                      $838.42
75900   26    Exchng Cath Thrombolytic Ther C+ Mntr Rs&I                        $24.65
75900   TC    Exchng Cath Thrombolytic Ther C+ Mntr Rs&I                      $813.77
75901         Mchnl Rmvl Pricath Obstr Matrl Rs&I                              $106.57
75901   26    Mchnl Rmvl Pricath Obstr Matrl Rs&I                               $25.41
75901   TC    Mchnl Rmvl Pricath Obstr Matrl Rs&I                               $81.16
75902         Mchnl Rmvl Intral Obstr Matrl Rs&I                               $101.74
75902   26    Mchnl Rmvl Intral Obstr Matrl Rs&I                                $20.50
75902   TC    Mchnl Rmvl Intral Obstr Matrl Rs&I                                $81.24
75940         Prq Plmt Ivc Filter Rs&I                                         $516.38
75940   26    Prq Plmt Ivc Filter Rs&I                                          $27.94
75940   TC    Prq Plmt Ivc Filter Rs&I                                         $488.44
75941         Percutaneous Placement Of Ivc Filter; Complete Procedure       $1,314.69
75941   TC    Percutaneous Placement Of Ivc Filter; Complete Procedure        $920.28
75945         Iv Us Rs&I 1St Vsl                                               $198.69
75945   26    Iv Us Rs&I 1St Vsl                                                $21.34
75945   TC    Iv Us Rs&I 1St Vsl                                               $177.35

                                          Page 140
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
75946         Iv Us Rs&I Ea Non-C Vsl                                          $110.95
75946   26    Iv Us Rs&I Ea Non-C Vsl                                           $21.38
75946   TC    Iv Us Rs&I Ea Non-C Vsl                                           $89.57
75950         Transcatheter Intravascular Occlusion (Eg, Balloon), Tempora   $1,633.34
75951         Transcatheter Intravascular Occlusion (Eg, Balloon), Tempora   $2,013.88
75951   TC    Transcatheter Intravascular Occlusion (Eg, Balloon), Tempora   $1,409.72
75952         Evasc Rpr Infrarnl Aaa/Dsj Rs&I                                  $241.71
75952   26    Evasc Rpr Infrarnl Aaa/Dsj Rs&I                                 $255.79
75952   TC    Evasc Rpr Infrarnl Aaa/Dsj Rs&I                                    $0.00
75953         Plmt Xtn Prosth Evasc Rpr Infrarnl Rs&I                          $101.78
75953   26    Plmt Xtn Prosth Evasc Rpr Infrarnl Rs&I                          $100.58
75953   TC    Plmt Xtn Prosth Evasc Rpr Infrarnl Rs&I                            $0.00
75954         Evasc Rpr Iliac Art Arysm Malfrmj/Trauma Rs&I                      $0.00
75954   26    Evasc Rpr Iliac Art Arysm Malfrmj/Trauma Rs&I                    $134.54
75954   TC    Evasc Rpr Iliac Art Arysm Malfrmj/Trauma Rs&I                      $0.00
75955         Transcatheter Intravascular Occlusion (Eg, Balloon, Coil, Or   $1,633.34
75956         Evasc Rpr Dta Coverage L Subcla Origin Rs&I                    $2,013.14
75956   26    Evasc Rpr Dta Coverage L Subcla Origin Rs&I                     $395.12
75956   TC    Evasc Rpr Dta Coverage L Subcla Origin Rs&I                    $1,409.20
75957   26    Evasc Rpr Dta X Coverage L Subcla Origin Rs&I                   $338.51
75958   26    Plmt Prox Xtn Prosth Evasc Rpr Dta Rs&I                          $225.66
75959   26    Plmt Dstl Xtn Prosth After Evasc Rpr Dta Rs&I                    $197.54
75960         Tcat Intro Iv Stent Prq&/Opn Rs&I Ea Vsl                         $620.49
75960   26    Tcat Intro Iv Stent Prq&/Opn Rs&I Ea Vsl                          $42.63
75960   TC    Tcat Intro Iv Stent Prq&/Opn Rs&I Ea Vsl                         $577.86
75961         Tcat Retrieval Prq Iv Fb Rs&I                                    $625.65
75961   26    Tcat Retrieval Prq Iv Fb Rs&I                                    $216.29
75961   TC    Tcat Retrieval Prq Iv Fb Rs&I                                    $409.36
75962         Trluml Balo Angiop Prph Art Rs&I                                $639.46
75962   26    Trluml Balo Angiop Prph Art Rs&I                                  $28.33
75962   TC    Trluml Balo Angiop Prph Art Rs&I                                $611.13
75963         Percutaneous Transluminal Angioplasty, Any Method, Periphera   $1,474.49
75963   TC    Percutaneous Transluminal Angioplasty, Any Method, Periphera   $1,032.14
75964         Trluml Balo Angiop Ea Prph Art Rs&I                             $343.60
75964   26    Trluml Balo Angiop Ea Prph Art Rs&I                               $18.38
75964   TC    Trluml Balo Angiop Ea Prph Art Rs&I                             $325.22
75965         Percutaneous Transluminal Angioplasty, Any Method, Each Addi    $855.43
75965   TC    Percutaneous Transluminal Angioplasty, Any Method, Each Addi    $598.80
75966         Trluml Balo Angiop Rnl/Oth Visc Art Rs&I                         $679.29
75966   26    Trluml Balo Angiop Rnl/Oth Visc Art Rs&I                          $67.66
75966   TC    Trluml Balo Angiop Rnl/Oth Visc Art Rs&I                         $611.63
75967         Percutaneous Transluminal Angioplasty, Any Method, Renal Or    $1,569.34
75967   TC    Percutaneous Transluminal Angioplasty, Any Method, Renal Or    $1,098.54
75968         Trluml Balo Angiop Ea Visc Art Rs&I                             $343.56
75968   26    Trluml Balo Angiop Ea Visc Art Rs&I                               $18.38
75968   TC    Trluml Balo Angiop Ea Visc Art Rs&I                             $325.18
75969         Percutaneous Transluminal Angioplasty, Any Method, Each Addi    $906.04
75969   TC    Percutaneous Transluminal Angioplasty, Any Method, Each Addi    $634.23
75970         Tcat Bx Rs&I                                                     $491.25
75970   26    Tcat Bx Rs&I                                                      $43.03
75970   TC    Tcat Bx Rs&I                                                     $448.22
75971         Transcatheter Biopsy; Complete Procedure                        $150.15
75971   TC    Transcatheter Biopsy; Complete Procedure                        $105.11
75972         Percutaneous Transluminal Angioplasty, Unilateral;              $382.20
75972   TC    Percutaneous Transluminal Angioplasty, Unilateral;              $267.54

                                           Page 141
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
75973         Percutaneous Transluminal Angioplasty, Unilateral;              $910.00
75973   TC    Percutaneous Transluminal Angioplasty, Unilateral;              $637.00
75974         Percutaneous Transluminal Angioplasty, Bilateral, Single Cat       $0.00
75974   TC    Percutaneous Transluminal Angioplasty, Bilateral, Single Cat       $0.00
75975         Percutaneous Transluminal Angioplasty, Bilateral, Single Cat       $0.00
75975   TC    Percutaneous Transluminal Angioplasty, Bilateral, Single Cat       $0.00
75976         Percutaneous Transluminal Angioplasty, Bilateral, Dual Cathe       $0.00
75976   TC    Percutaneous Transluminal Angioplasty, Bilateral, Dual Cathe       $0.00
75977         Percutaneous Transluminal Angioplasty, Bilateral, Dual Cathe   $1,800.00
75977   TC    Percutaneous Transluminal Angioplasty, Bilateral, Dual Cathe   $1,260.00
75978         Trluml Balo Angiop Ven Rs&I                                     $638.28
75978   26    Trluml Balo Angiop Ven Rs&I                                       $27.19
75978   TC    Trluml Balo Angiop Ven Rs&I                                     $611.09
75979         Percutaneous Transluminal Angioplasty, Venous (Eg, Subclavia       $0.00
75979   TC    Percutaneous Transluminal Angioplasty, Venous (Eg, Subclavia       $0.00
75980         Prq Transhepatc Biliary Drg C+ Mntr Rs&I                         $284.23
75980   26    Prq Transhepatc Biliary Drg C+ Mntr Rs&I                          $72.99
75980   TC    Prq Transhepatc Biliary Drg C+ Mntr Rs&I                         $211.24
75981         Percutaneous Transhepatic Biliary Drainage With Contrast Mon    $209.30
75981   TC    Percutaneous Transhepatic Biliary Drainage With Contrast Mon    $146.51
75982         Prq Biliary Drg/Drg Stent Rs&I                                   $310.32
75982   26    Prq Biliary Drg/Drg Stent Rs&I                                    $72.61
75982   TC    Prq Biliary Drg/Drg Stent Rs&I                                   $237.71
75983         Percutaneous Placement Of Drainage Catheter For Combined Int    $495.96
75983   TC    Percutaneous Placement Of Drainage Catheter For Combined Int    $347.17
75984         Chng Prq Tube/Drg Cath C+ Mntr Rs&I                              $113.32
75984   26    Chng Prq Tube/Drg Cath C+ Mntr Rs&I                               $36.91
75984   TC    Chng Prq Tube/Drg Cath C+ Mntr Rs&I                               $76.41
75985         Change Of Percutaneous Drainage Catheter With Contrast Monit    $154.70
75985   TC    Change Of Percutaneous Drainage Catheter With Contrast Monit    $108.29
75989         Rad Gid Prq Drg W/Plmt Cath Rs&I                                 $183.42
75989   26    Rad Gid Prq Drg W/Plmt Cath Rs&I                                  $60.16
75989   TC    Rad Gid Prq Drg W/Plmt Cath Rs&I                                 $123.26
75990         Radiological Guidance For Percutaneous Drainage Of Abscess,     $261.64
75990   TC    Radiological Guidance For Percutaneous Drainage Of Abscess,     $183.15
75992         Trluml Athrc Prph Art Rs&I                                       $638.65
75992   26    Trluml Athrc Prph Art Rs&I                                        $27.59
75992   TC    Trluml Athrc Prph Art Rs&I                                       $611.06
75993         Trluml Athrc Ea Prph Art Rs&I                                    $343.93
75993   26    Trluml Athrc Ea Prph Art Rs&I                                     $18.74
75993   TC    Trluml Athrc Ea Prph Art Rs&I                                    $325.19
75994         Trluml Athrc Rnl Rs&I                                            $679.29
75994   26    Trluml Athrc Rnl Rs&I                                             $67.66
75994   TC    Trluml Athrc Rnl Rs&I                                            $611.63
75995         Trluml Athrc Visc Rs&I                                           $679.65
75995   26    Trluml Athrc Visc Rs&I                                            $68.03
75995   TC    Trluml Athrc Visc Rs&I                                           $611.62
75996         Trluml Athrc Ea Visc Art Rs&I                                    $343.19
75996   26    Trluml Athrc Ea Visc Art Rs&I                                     $18.02
75996   TC    Trluml Athrc Ea Visc Art Rs&I                                    $325.17
75998         Fluoroscopic Guidance For Central Venous Access Device Place      $72.88
75998   26    Fluoroscopic Guidance For Central Venous Access Device Place      $20.72
75998   TC    Fluoroscopic Guidance For Central Venous Access Device Place      $52.16
76000         Fluor Spx <1 Hr Phys Tm Oth/Thn 71023/71034                       $59.26
76000   26    Fluor Spx <1 Hr Phys Tm Oth/Thn 71023/71034                        $8.47

                                           Page 142
                         MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
76000   TC    Fluor Spx <1 Hr Phys Tm Oth/Thn 71023/71034                     $50.79
76001         Fluor Phys Tm >1 Hr Assisting Non-Rad Phys                     $136.05
76001   26    Fluor Phys Tm >1 Hr Assisting Non-Rad Phys                      $34.28
76001   TC    Fluor Phys Tm >1 Hr Assisting Non-Rad Phys                     $101.77
76003         Fluoroscopic Guidance For Needle Placement (Eg, Biopsy, Aspi    $78.68
76003   26    Fluoroscopic Guidance For Needle Placement (Eg, Biopsy, Aspi    $27.70
76003   TC    Fluoroscopic Guidance For Needle Placement (Eg, Biopsy, Aspi    $50.98
76005         Fluoroscopic Guidance And Localization Of Needle Or Catheter    $80.56
76005   26    Fluoroscopic Guidance And Localization Of Needle Or Catheter    $29.57
76005   TC    Fluoroscopic Guidance And Localization Of Needle Or Catheter    $50.99
76006         Manual Application Of Stress Performed By Physician For Join    $24.28
76006   26    Manual Application Of Stress Performed By Physician For Join     $7.28
76006   TC    Manual Application Of Stress Performed By Physician For Join    $17.00
76010         Radex From Nose Rectum Fb 1 View Chld                           $29.12
76010   26    Radex From Nose Rectum Fb 1 View Chld                            $9.22
76010   TC    Radex From Nose Rectum Fb 1 View Chld                           $19.90
76012         Radiological Supervision And Interpretation, Percutaneous Ve    $78.21
76012   26    Radiological Supervision And Interpretation, Percutaneous Ve    $77.10
76012   TC    Radiological Supervision And Interpretation, Percutaneous Ve     $0.00
76013         Radiological Supervision And Interpretation, Percutaneous Ve    $92.99
76013   26    Radiological Supervision And Interpretation, Percutaneous Ve    $92.29
76013   TC    Radiological Supervision And Interpretation, Percutaneous Ve     $0.00
76020         Bone Age Studies                                                $29.49
76020   26    Bone Age Studies                                                 $9.58
76020   TC    Bone Age Studies                                                $19.91
76040         Bone Length Studies (Orthoroentgenogram, Scanogram)             $45.88
76040   26    Bone Length Studies (Orthoroentgenogram, Scanogram)             $14.80
76040   TC    Bone Length Studies (Orthoroentgenogram, Scanogram)             $31.08
76061         Radiologic Examination, Osseous Survey; Limited (Eg, For Met    $62.05
76061   26    Radiologic Examination, Osseous Survey; Limited (Eg, For Met    $22.90
76061   TC    Radiologic Examination, Osseous Survey; Limited (Eg, For Met    $39.15
76062         Radiologic Examination, Osseous Survey; Complete (Axial And     $83.39
76062   26    Radiologic Examination, Osseous Survey; Complete (Axial And     $27.30
76062   TC    Radiologic Examination, Osseous Survey; Complete (Axial And     $56.09
76065         Radiologic Examination, Osseous Survey, Infant                  $64.36
76065   26    Radiologic Examination, Osseous Survey, Infant                  $35.14
76065   TC    Radiologic Examination, Osseous Survey, Infant                  $29.22
76066         Joint Survey, Single View, Two Or More Joints (Specify)         $59.75
76066   26    Joint Survey, Single View, Two Or More Joints (Specify)         $16.23
76066   TC    Joint Survey, Single View, Two Or More Joints (Specify)         $43.52
76070         Computed Tomography, Bone Mineral Density Study, One Or More   $127.26
76070   26    Computed Tomography, Bone Mineral Density Study, One Or More    $12.51
76070   TC    Computed Tomography, Bone Mineral Density Study, One Or More   $114.75
76071         Computed Tomography, Bone Mineral Density Study, One Or More   $121.30
76071   26    Computed Tomography, Bone Mineral Density Study, One Or More    $10.99
76071   TC    Computed Tomography, Bone Mineral Density Study, One Or More   $110.31
76075         Dual Energy X-Ray Absorptiometry (Dxa), Bone Density Study,    $135.74
76075   26    Dual Energy X-Ray Absorptiometry (Dxa), Bone Density Study,     $15.08
76075   TC    Dual Energy X-Ray Absorptiometry (Dxa), Bone Density Study,    $120.66
76076         Dual Energy X-Ray Absorptiometry (Dxa), Bone Density Study,     $41.33
76076   26    Dual Energy X-Ray Absorptiometry (Dxa), Bone Density Study,     $11.44
76076   TC    Dual Energy X-Ray Absorptiometry (Dxa), Bone Density Study,     $29.89
76077         Dual Energy X-Ray Absorptiometry (Dxa), Bone Density Study,     $39.11
76077   26    Dual Energy X-Ray Absorptiometry (Dxa), Bone Density Study,      $9.09
76077   tc    Dual Energy X-Ray Absorptiometry (Dxa), Bone Density Study,     $30.02

                                          Page 143
                         MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
76078         Radiographic Absorptiometry (Eg, Photodensitometry, Radiogra      $40.22
76078   26    Radiographic Absorptiometry (Eg, Photodensitometry, Radiogra      $10.33
76078   TC    Radiographic Absorptiometry (Eg, Photodensitometry, Radiogra      $29.89
76080         Rad Xm Absc/Fstl/Sinus Trc Rad S&I                                $68.70
76080   26    Rad Xm Absc/Fstl/Sinus Trc Rad S&I                                $27.33
76080   TC    Rad Xm Absc/Fstl/Sinus Trc Rad S&I                                $41.37
76081         Radiologic Examination, Fistula Or Sinus Tract Study; Comple      $72.80
76081   26    Radiologic Examination, Fistula Or Sinus Tract Study; Comple      $21.84
76081   TC    Radiologic Examination, Fistula Or Sinus Tract Study; Comple      $50.96
76086         Mammary Ductogram Or Galactogram, Single Duct, Radiological     $120.01
76086   26    Mammary Ductogram Or Galactogram, Single Duct, Radiological       $18.41
76086   TC    Mammary Ductogram Or Galactogram, Single Duct, Radiological     $101.60
76087         Mammary Ductogram Or Galactogram, Single Duct; Complete Proc      $72.80
76087   TC    Mammary Ductogram Or Galactogram, Single Duct; Complete Proc      $50.96
76088         Mammary Ductogram Or Galactogram, Multiple Ducts, Radiologic    $165.20
76088   26    Mammary Ductogram Or Galactogram, Multiple Ducts, Radiologic      $22.81
76088   TC    Mammary Ductogram Or Galactogram, Multiple Ducts, Radiologic    $142.39
76089         Mammary Ductogram Or Galactogram, Multiple Ducts; Complete P      $91.00
76089   TC    Mammary Ductogram Or Galactogram, Multiple Ducts; Complete P      $63.70
76093         Magnetic Resonance Imaging, Breast, Without And/Or With Cont    $766.51
76093   26    Magnetic Resonance Imaging, Breast, Without And/Or With Cont      $82.40
76093   TC    Magnetic Resonance Imaging, Breast, Without And/Or With Cont    $684.11
76094         Magnetic Resonance Imaging, Breast, Without And/Or With Cont   $1,009.95
76094   26    Magnetic Resonance Imaging, Breast, Without And/Or With Cont      $82.31
76094   TC    Magnetic Resonance Imaging, Breast, Without And/Or With Cont    $927.64
76095         Stereotactic Localization Guidance For Breast Biopsy Or Need    $360.44
76095   26    Stereotactic Localization Guidance For Breast Biopsy Or Need      $81.82
76095   TC    Stereotactic Localization Guidance For Breast Biopsy Or Need    $278.62
76096         Mammographic Guidance For Needle Placement, Breast (Eg, For       $80.16
76096   26    Mammographic Guidance For Needle Placement, Breast (Eg, For       $29.19
76096   TC    Mammographic Guidance For Needle Placement, Breast (Eg, For       $50.97
76097         Localization Of Breast Nodule Or Calcification Before Operat      $69.34
76097   26    Localization Of Breast Nodule Or Calcification Before Operat      $20.80
76097   TC    Localization Of Breast Nodule Or Calcification Before Operat      $48.54
76098         Rad Xm Surg Spec                                                  $23.99
76098   26    Rad Xm Surg Spec                                                   $8.12
76098   TC    Rad Xm Surg Spec                                                  $15.87
76100         Radex 1 Plne Bdy Sctj Oth/Thn Urograpy                            $78.72
76100   26    Radex 1 Plne Bdy Sctj Oth/Thn Urograpy                            $29.94
76100   TC    Radex 1 Plne Bdy Sctj Oth/Thn Urograpy                            $48.78
76101         Radex Cplx Motion Bdy Sctj Oth/Thn Urograpy Uni                   $85.70
76101   26    Radex Cplx Motion Bdy Sctj Oth/Thn Urograpy Uni                   $29.92
76101   TC    Radex Cplx Motion Bdy Sctj Oth/Thn Urograpy Uni                   $55.78
76102         Radex Cplx Motion Bdy Sctj Oth/Thn Urograpy Bi                    $98.60
76102   26    Radex Cplx Motion Bdy Sctj Oth/Thn Urograpy Bi                    $30.28
76102   TC    Radex Cplx Motion Bdy Sctj Oth/Thn Urograpy Bi                    $68.32
76120         Cineradiograpy/Vidradiograpy Xcpt Where Spec                      $60.90
76120   26    Cineradiograpy/Vidradiograpy Xcpt Where Spec                      $19.56
76120   TC    Cineradiograpy/Vidradiograpy Xcpt Where Spec                      $41.34
76125         Cineradiograpy/Vidradiograpy Routine Xm                           $44.66
76125   26    Cineradiograpy/Vidradiograpy Routine Xm                           $13.66
76125   TC    Cineradiograpy/Vidradiograpy Routine Xm                           $31.00
76127         Prcdrs Usng Polaroid/Smlr Photo Media                              $4.55
76127   26    Prcdrs Usng Polaroid/Smlr Photo Media                              $1.37
76127   TC    Prcdrs Usng Polaroid/Smlr Photo Media                              $3.19

                                          Page 144
                         MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
76130         Radlgcl Xm;Bedside/Operatng Rm,Not Othrws Spcfd                 $25.00
76130   26    Radlgcl Xm;Bedside/Operatng Rm,Not Othrws Spcfd                  $7.50
76130   TC    Radlgcl Xm;Bedside/Operatng Rm,Not Othrws Spcfd                 $17.50
76135         Rad Xm;In Home                                                  $54.60
76135   26    Rad Xm;In Home                                                  $16.38
76135   TC    Rad Xm;In Home                                                  $38.22
76137         Rad Xm;After Regular Hours                                      $25.00
76137   26    Rad Xm;After Regular Hours                                       $7.50
76137   TC    Rad Xm;After Regular Hours                                      $17.50
76140         Consltj X-Ray Xm Made Elsewhere Wrttn Reprt                     $27.30
76150         Xeroradiograpy                                                  $15.79
76300         Thermograph Examination                                          $0.00
76300   26    Thermograph Examination                                          $0.00
76300   TC    Thermograph Examination                                          $0.00
76350         Subtrcj Conjunct C+ Std                                         $16.38
76355         Computed Tomography Guidance For Stereotactic Localization     $382.44
76355   26    Computed Tomography Guidance For Stereotactic Localization      $61.84
76355   TC    Computed Tomography Guidance For Stereotactic Localization     $320.60
76360         Computed Tomography Guidance For Needle Placement (Eg, Biops   $379.07
76360   26    Computed Tomography Guidance For Needle Placement (Eg, Biops    $58.53
76360   TC    Computed Tomography Guidance For Needle Placement (Eg, Biops   $320.54
76361         Computerized Tomography Guidance For Needle Biopsy; Complete   $497.77
76361   26    Computerized Tomography Guidance For Needle Biopsy; Complete   $149.33
76361   TC    Computerized Tomography Guidance For Needle Biopsy; Complete   $348.44
76362         Computed Tomography Guidance For, And Monitoring Of, Viscera   $567.54
76362   26    Computed Tomography Guidance For, And Monitoring Of, Viscera   $204.94
76362   TC    Computed Tomography Guidance For, And Monitoring Of, Viscera   $362.60
76365         Ct Guidance Cyst Aspirat-Rad S & I                             $374.74
76365   26    Ct Guidance Cyst Aspirat-Rad S & I                             $112.42
76365   TC    Ct Guidance Cyst Aspirat-Rad S & I                             $262.32
76366         Computerized Tomography Guidance For Cyst Aspiration; Comple    $36.40
76366   TC    Computerized Tomography Guidance For Cyst Aspiration; Comple    $25.48
76370         Computed Tomography Guidance For Placement Of Radiation Ther   $158.60
76370   26    Computed Tomography Guidance For Placement Of Radiation Ther    $43.52
76370   TC    Computed Tomography Guidance For Placement Of Radiation Ther   $115.08
76375         Coronal, Sagittal, Multiplanar, Oblique, 3-Dimensional And/O   $145.16
76375   26    Coronal, Sagittal, Multiplanar, Oblique, 3-Dimensional And/O     $8.09
76375   TC    Coronal, Sagittal, Multiplanar, Oblique, 3-Dimensional And/O   $137.07
76376         3D Rndr I&R Ct Mri Us/Oth X Req Postpcx                        $143.21
76376   26    3D Rndr I&R Ct Mri Us/Oth X Req Postpcx                         $11.01
76376   TC    3D Rndr I&R Ct Mri Us/Oth X Req Postpcx                        $132.20
76377         3D Rndr I&R Ct Mri Us/Oth Req Postpcx                          $184.84
76377   26    3D Rndr I&R Ct Mri Us/Oth Req Postpcx                           $43.33
76377   TC    3D Rndr I&R Ct Mri Us/Oth Req Postpcx                          $141.51
76380         Ct Lmtd/Loclzd F-Up Std                                        $186.17
76380   26    Ct Lmtd/Loclzd F-Up Std                                         $50.14
76380   TC    Ct Lmtd/Loclzd F-Up Std                                        $136.03
76390         Mri Spectroscopy                                               $498.34
76390   26    Mri Spectroscopy                                                $71.41
76390   TC    Mri Spectroscopy                                               $426.93
76393         Magnetic Resonance Guidance For Needle Placement (Eg, For Bi   $510.34
76393   26    Magnetic Resonance Guidance For Needle Placement (Eg, For Bi    $76.55
76393   TC    Magnetic Resonance Guidance For Needle Placement (Eg, For Bi   $433.79
76394         Magnetic Resonance Guidance For, And Monitoring Of, Visceral   $692.36
76394   26    Magnetic Resonance Guidance For, And Monitoring Of, Visceral   $217.40

                                          Page 145
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
76394   TC    Magnetic Resonance Guidance For, And Monitoring Of, Visceral   $474.96
76400         Magnetic Resonance (Eg, Proton) Imaging, Bone Marrow Blood S   $516.44
76400   26    Magnetic Resonance (Eg, Proton) Imaging, Bone Marrow Blood S    $80.98
76400   TC    Magnetic Resonance (Eg, Proton) Imaging, Bone Marrow Blood S   $435.46
76496         Unlis Fluor Px                                                   $0.00
76496   26    Unlis Fluor Px                                                   $0.00
76496   TC    Unlis Fluor Px                                                   $0.00
76497         Unlis Ct Px                                                      $0.00
76497   26    Unlis Ct Px                                                      $0.00
76497   TC    Unlis Ct Px                                                      $0.00
76498         Unlis Mri Px                                                     $0.00
76498   26    Unlis Mri Px                                                     $0.00
76498   TC    Unlis Mri Px                                                     $0.00
76499         Unlis Dx Radiograpic Px                                          $0.00
76499   26    Unlis Dx Radiograpic Px                                          $0.00
76499   TC    Unlis Dx Radiograpic Px                                          $0.00
76500         Echoencephalography, A-Mode, Diencephalic Midline               $63.70
76505         Echncephalography,A-Mode;Complete                               $63.70
76506         Echoencephalograpy R-T Img                                      $89.75
76506   26    Echoencephalograpy R-T Img                                      $33.98
76506   TC    Echoencephalograpy R-T Img                                      $55.77
76510         Oph Us Dx B-Scan&Quan A-Scan Sm Pt Enctr                       $169.55
76510   26    Oph Us Dx B-Scan&Quan A-Scan Sm Pt Enctr                        $85.34
76510   TC    Oph Us Dx B-Scan&Quan A-Scan Sm Pt Enctr                        $84.21
76511         Oph Us Dx Quan A-Scan Only                                     $105.58
76511   26    Oph Us Dx Quan A-Scan Only                                      $50.20
76511   TC    Oph Us Dx Quan A-Scan Only                                      $55.38
76512         Oph Us Dx B-Scan +-A-Scan                                       $93.02
76512   26    Oph Us Dx B-Scan +-A-Scan                                       $35.80
76512   TC    Oph Us Dx B-Scan +-A-Scan                                       $57.22
76513         Oph Us Dx Ant Sgm Us Immersion B-Scan/Hr Biom                   $96.31
76513   26    Oph Us Dx Ant Sgm Us Immersion B-Scan/Hr Biom                   $35.79
76513   TC    Oph Us Dx Ant Sgm Us Immersion B-Scan/Hr Biom                   $60.52
76514         Oph Us Dx Crnl Pachymetry Uni/Bi                                $12.27
76514   26    Oph Us Dx Crnl Pachymetry Uni/Bi                                 $9.67
76514   TC    Oph Us Dx Crnl Pachymetry Uni/Bi                                 $2.60
76515         Tomography, W/W/O A Or M-Mode                                  $273.00
76515   26    Tomography, W/W/O A Or M-Mode                                   $81.90
76515   TC    Tomography, W/W/O A Or M-Mode                                  $191.10
76516         Oph Bmtry Us Echograpy A-Scan                                   $76.37
76516   26    Oph Bmtry Us Echograpy A-Scan                                   $29.52
76516   TC    Oph Bmtry Us Echograpy A-Scan                                   $46.85
76517         B-Scan A/Or Real Time W/Image Documentation                    $136.50
76517   26    B-Scan A/Or Real Time W/Image Documentation                     $40.95
76517   TC    B-Scan A/Or Real Time W/Image Documentation                     $95.55
76519         Oph Bmtry Us Echograpy A-Scan Io Lens Pwr Cal                   $79.65
76519   26    Oph Bmtry Us Echograpy A-Scan Io Lens Pwr Cal                   $29.50
76519   TC    Oph Bmtry Us Echograpy A-Scan Io Lens Pwr Cal                   $50.15
76529         Oph Ultrasonic Fb Loclzj                                        $76.07
76529   26    Oph Ultrasonic Fb Loclzj                                        $30.65
76529   TC    Oph Ultrasonic Fb Loclzj                                        $45.42
76530         Echography Thyroid;A-Mode                                       $63.70
76530   26    Echography Thyroid;A-Mode                                       $19.11
76530   TC    Echography Thyroid;A-Mode                                       $44.59
76536         Us Soft Tiss Head&Nck R-T Img                                   $84.13

                                           Page 146
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
76536    26   Us Soft Tiss Head&Nck R-T Img                                   $28.41
76536   TC    Us Soft Tiss Head&Nck R-T Img                                   $55.72
76601         Echogrphy,Chest;A-Mode                                          $27.30
76601   26    Echogrphy,Chest;A-Mode                                           $8.19
76601   TC    Echogrphy,Chest;A-Mode                                          $19.11
76604         Us Chest R-T W/Image Documentation                              $78.61
76604   26    Us Chest R-T W/Image Documentation                              $27.68
76604   TC    Us Chest R-T W/Image Documentation                              $50.93
76620         Echocardiography, M-Mode                                        $63.70
76620   26    Echocardiography, M-Mode                                        $19.11
76620   TC    Echocardiography, M-Mode                                        $44.59
76625         Echocardiography, M-Mode                                        $36.40
76625   26    Echocardiography, M-Mode                                        $10.92
76625   TC    Echocardiography, M-Mode                                        $25.48
76627         Echocardiography, Real-Time With Image Documentation (2D)        $0.00
76628         Echocardiography, Real-Time With Image Documentation (2D)        $0.00
76629         Echocardiography, M-Mode And Real Time With Image               $54.60
76629   26    Echocardiography, M-Mode And Real Time With Image               $16.38
76629   TC    Echocardiography, M-Mode And Real Time With Image               $38.22
76640         Echography,Breast;A-Mode                                        $45.50
76640   26    Echography,Breast;A-Mode                                        $13.65
76640   TC    Echography,Breast;A-Mode                                        $31.85
76645         Us Breast R-T W/Image Documentation                             $69.51
76645   26    Us Breast R-T W/Image Documentation                             $28.10
76645   TC    Us Breast R-T W/Image Documentation                             $41.41
76700         Us Abdominal R-T W/Image Documentation                         $118.92
76700   26    Us Abdominal R-T W/Image Documentation                          $41.73
76700   TC    Us Abdominal R-T W/Image Documentation                          $77.19
76705         Us Retroperitoneal R-T W/Image Compl                            $86.43
76705   26    Us Retroperitoneal R-T W/Image Compl                            $30.66
76705   TC    Us Retroperitoneal R-T W/Image Compl                            $55.77
76770         Us Retroperitoneal R-T W/Image Compl                           $115.16
76770   26    Us Retroperitoneal R-T W/Image Compl                            $38.01
76770   TC    Us Retroperitoneal R-T W/Image Compl                            $77.15
76775         Us Rpr B-Scan&/R-T Img Lmtd                                     $85.70
76775   26    Us Rpr B-Scan&/R-T Img Lmtd                                     $29.92
76775   TC    Us Rpr B-Scan&/R-T Img Lmtd                                     $55.78
76778         Ultrasound, Transplanted Kidney, B-Scan And/Or Real Time Wit   $115.16
76778   26    Ultrasound, Transplanted Kidney, B-Scan And/Or Real Time Wit    $38.01
76778   TC    Ultrasound, Transplanted Kidney, B-Scan And/Or Real Time Wit    $77.15
76800         Us Spi Canal&Cnts                                              $112.48
76800   26    Us Spi Canal&Cnts                                               $56.61
76800   TC    Us Spi Canal&Cnts                                               $55.87
76801         Us Pg Uter Img F&Mat 14 Wk Tabdl 1/1St Gestation               $133.35
76801   26    Us Pg Uter Img F&Mat 14 Wk Tabdl 1/1St Gestation                $51.34
76801   TC    Us Pg Uter Img F&Mat 14 Wk Tabdl 1/1St Gestation                $82.01
76802         Us Pg Uter F&Mat 14 Wk Tabdl Ea Gestation                       $87.21
76802   26    Us Pg Uter F&Mat 14 Wk Tabdl Ea Gestation                       $43.42
76802   TC    Us Pg Uter F&Mat 14 Wk Tabdl Ea Gestation                       $43.79
76805         Us Pg Uter F&Mat After 1St Tri 1/1St Gestation                 $133.35
76805   26    Us Pg Uter F&Mat After 1St Tri 1/1St Gestation                  $51.34
76805   TC    Us Pg Uter F&Mat After 1St Tri 1/1St Gestation                  $82.01
76810         Us Pg Uter F&Mat After 1St Tri Abdl Ea Gestation               $100.29
76810   26    Us Pg Uter F&Mat After 1St Tri Abdl Ea Gestation                $52.57
76810   TC    Us Pg Uter F&Mat After 1St Tri Abdl Ea Gestation                $47.72

                                            Page 147
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                      Amount
76811         Us Pg Uter F&Mat Detailed Ftl Xm 1St Gestation   $249.13
76811   26    Us Pg Uter F&Mat Detailed Ftl Xm 1St Gestation   $101.72
76811   TC    Us Pg Uter F&Mat Detailed Ftl Xm 1St Gestation   $147.41
76812         Us Pg Uter F&Mat Detailed Ftl Antmc Xm Ea        $150.56
76812   26    Us Pg Uter F&Mat Detailed Ftl Antmc Xm Ea         $95.50
76812   TC    Us Pg Uter F&Mat Detailed Ftl Antmc Xm Ea         $55.06
76815         Us Pg Uter R-T Img Lmtd 1+ Fetuses                $88.96
76815   26    Us Pg Uter R-T Img Lmtd 1+ Fetuses                $33.22
76815   TC    Us Pg Uter R-T Img Lmtd 1+ Fetuses                $55.74
76816         Us Pg Uter R-T Img F-Up Tabdl Appr Pr Fetus       $87.58
76816   26    Us Pg Uter R-T Img F-Up Tabdl Appr Pr Fetus       $43.97
76816   TC    Us Pg Uter R-T Img F-Up Tabdl Appr Pr Fetus       $43.61
76817         Us Pg Uter R-T Img Trvg                           $96.99
76817   26    Us Pg Uter R-T Img Trvg                           $38.72
76817   TC    Us Pg Uter R-T Img Trvg                           $58.27
76818         Ftl Biophysical Profile Non-Strs Tstg            $118.34
76818   26    Ftl Biophysical Profile Non-Strs Tstg             $54.73
76818   TC    Ftl Biophysical Profile Non-Strs Tstg             $63.61
76819         Ftl Biophysical Profile W/O Non-Strs Tstg        $103.01
76819   26    Ftl Biophysical Profile W/O Non-Strs Tstg         $39.50
76819   TC    Ftl Biophysical Profile W/O Non-Strs Tstg         $63.51
76820         Dop Velocimetry Ftl Umbilical Art                 $92.22
76820   26    Dop Velocimetry Ftl Umbilical Art                 $27.26
76820   TC    Dop Velocimetry Ftl Umbilical Art                 $64.96
76821         Dop Velocimetry Ftl Middle Cere Art              $102.78
76821   26    Dop Velocimetry Ftl Middle Cere Art               $37.82
76821   TC    Dop Velocimetry Ftl Middle Cere Art               $64.96
76825         Echo Ftl Cv Sys R-T Rec                          $163.89
76825   26    Echo Ftl Cv Sys R-T Rec                           $86.57
76825   TC    Echo Ftl Cv Sys R-T Rec                           $77.32
76826         Echo Ftl Cv Sys R-T Rec Repeat Std                $71.17
76826   26    Echo Ftl Cv Sys R-T Rec Repeat Std                $43.00
76826   TC    Echo Ftl Cv Sys R-T Rec Repeat Std                $28.17
76827         Dop Echo Ftl Spectral Display Compl               $98.56
76827   26    Dop Echo Ftl Spectral Display Compl               $30.27
76827   TC    Dop Echo Ftl Spectral Display Compl               $68.29
76828         Dop Echo Ftl Plsd Spectral Display Repeat Std     $73.91
76828   26    Dop Echo Ftl Plsd Spectral Display Repeat Std     $29.56
76828   TC    Dop Echo Ftl Plsd Spectral Display Repeat Std     $44.35
76830         Us Trvg                                           $95.36
76830   26    Us Trvg                                           $35.48
76830   TC    Us Trvg                                           $59.88
76831         Saline Nfs Shg Sis Col Flo Dop Pfrmd              $96.77
76831   26    Saline Nfs Shg Sis Col Flo Dop Pfrmd              $36.94
76831   TC    Saline Nfs Shg Sis Col Flo Dop Pfrmd              $59.83
76855         Echography, Pelvic Area (Doppler)                 $86.22
76855   26    Echography, Pelvic Area (Doppler)                 $25.87
76855   TC    Echography, Pelvic Area (Doppler)                 $60.35
76856         Us Pelvic Nonob Real-Time Img Complete            $95.36
76856   26    Us Pelvic Nonob Real-Time Img Complete            $35.48
76856   TC    Us Pelvic Nonob Real-Time Img Complete            $59.88
76857         Us Pel Nonob B-Scan&/R-T Img Lmtd/F-Up+C97        $79.52
76857   26    Us Pel Nonob B-Scan&/R-T Img Lmtd/F-Up+C97        $19.51
76857   TC    Us Pel Nonob B-Scan&/R-T Img Lmtd/F-Up+C97        $60.01
76870         Us Scrotum&Cnts                                   $92.77

                                            Page 148
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
76870    26   Us Scrotum&Cnts                                                 $32.90
76870   TC    Us Scrotum&Cnts                                                 $59.87
76872         Us Transrct                                                    $108.19
76872   26    Us Transrct                                                     $35.82
76872   TC    Us Transrct                                                     $72.37
76873         Us Transrct Prst8 Vol Std Brachytx Plnning Spx                 $163.03
76873   26    Us Transrct Prst8 Vol Std Brachytx Plnning Spx                  $79.30
76873   TC    Us Transrct Prst8 Vol Std Brachytx Plnning Spx                  $83.73
76880         Us Extremity Non-Vasc Real-Time Img                             $86.43
76880   26    Us Extremity Non-Vasc Real-Time Img                             $30.66
76880   TC    Us Extremity Non-Vasc Real-Time Img                             $55.77
76885         Us Inft Hips R-T Img Dynamic Req Phys Mnpj                      $97.96
76885   26    Us Inft Hips R-T Img Dynamic Req Phys Mnpj                      $38.08
76885   TC    Us Inft Hips R-T Img Dynamic Req Phys Mnpj                      $59.88
76886         Us Inft Hips R-T Img Lmtd Static X Phys Mnpj                    $87.92
76886   26    Us Inft Hips R-T Img Lmtd Static X Phys Mnpj                    $32.13
76886   TC    Us Inft Hips R-T Img Lmtd Static X Phys Mnpj                    $55.79
76900         Peripheral Flow Stdy;Arterial Only                             $109.20
76900   26    Peripheral Flow Stdy;Arterial Only                              $32.76
76900   TC    Peripheral Flow Stdy;Arterial Only                              $76.44
76910         Peripheral Flow Stdy; Venous Only                              $109.20
76910   26    Peripheral Flow Stdy; Venous Only                               $32.76
76910   TC    Peripheral Flow Stdy; Venous Only                               $76.44
76920         Peripheral Flow Stdy; Arterial & Venous                        $100.10
76920   26    Peripheral Flow Stdy; Arterial & Venous                         $30.03
76920   TC    Peripheral Flow Stdy; Arterial & Venous                         $70.07
76925         Echography, Peripheral Vascular System (Eg, B-Scan, Doppler    $100.10
76925   26    Echography, Peripheral Vascular System (Eg, B-Scan, Doppler     $30.03
76925   TC    Echography, Peripheral Vascular System (Eg, B-Scan, Doppler     $70.07
76926         Echography, Head And Trunk, Vascular System (Eg, Duplex Dopp   $101.68
76926   26    Echography, Head And Trunk, Vascular System (Eg, Duplex Dopp    $30.50
76926   TC    Echography, Head And Trunk, Vascular System (Eg, Duplex Dopp    $71.18
76930         Us Pricardiocnts Img S&I                                        $94.90
76930   26    Us Pricardiocnts Img S&I                                        $35.08
76930   TC    Us Pricardiocnts Img S&I                                        $59.83
76931         Ultrasonic Guidance For Pericardiocentesis; Complete Procedu   $188.47
76931   TC    Ultrasonic Guidance For Pericardiocentesis; Complete Procedu   $131.93
76932         Us Endomyocrd Bx Img S&I                                        $94.90
76932   26    Us Endomyocrd Bx Img S&I                                        $35.08
76932   TC    Us Endomyocrd Bx Img S&I                                        $59.83
76933         Ultrasonic Guidance For Endomyocardial Biopsy; Complete Proc   $600.00
76933   TC    Ultrasonic Guidance For Endomyocardial Biopsy; Complete Proc   $420.00
76934         Ultrason Guid Thoracen/Abd Paracen                              $97.46
76934   26    Ultrason Guid Thoracen/Abd Paracen                              $29.24
76934   TC    Ultrason Guid Thoracen/Abd Paracen                              $68.22
76935         Ultrasonic Guidance For Thoracentesis; Complete Procedure      $153.54
76935   TC    Ultrasonic Guidance For Thoracentesis; Complete Procedure      $107.48
76936         Us Cmprn Rpr Artl Pseudoarysm/Arven Fstl                       $348.31
76936   26    Us Cmprn Rpr Artl Pseudoarysm/Arven Fstl                       $102.58
76936   TC    Us Cmprn Rpr Artl Pseudoarysm/Arven Fstl                       $245.73
76937         Us Vasc Access Sits Vsl Patency Ndl Entry                       $34.47
76937   26    Us Vasc Access Sits Vsl Patency Ndl Entry                       $16.86
76937   TC    Us Vasc Access Sits Vsl Patency Ndl Entry                       $17.61
76938         Ultrason Guidan Cyst Aspirat-S & I                              $93.55
76938   26    Ultrason Guidan Cyst Aspirat-S & I                              $28.07

                                           Page 149
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
76938   TC    Ultrason Guidan Cyst Aspirat-S & I                              $65.49
76939         Ultrasonic Guidance For Cyst (Any Location), Or Renal Pelvis   $229.57
76939   TC    Ultrasonic Guidance For Cyst (Any Location), Or Renal Pelvis   $160.70
76940         Us &Mntr Parenchymal Tissue Ablation                           $171.01
76940   26    Us &Mntr Parenchymal Tissue Ablation                           $103.58
76940   TC    Us &Mntr Parenchymal Tissue Ablation                            $67.43
76941         Us Intrauterine Ftl Tfuj/Cordocnts Img S&I                     $129.17
76941   26    Us Intrauterine Ftl Tfuj/Cordocnts Img S&I                      $69.58
76941   TC    Us Intrauterine Ftl Tfuj/Cordocnts Img S&I                      $59.59
76942         Us Ndl Plmt Img S&I                                            $131.90
76942   26    Us Ndl Plmt Img S&I                                             $34.64
76942   TC    Us Ndl Plmt Img S&I                                             $97.26
76943         Ultrasonic Guidance For Needle Biopsy; Complete Procedure      $229.57
76943   TC    Ultrasonic Guidance For Needle Biopsy; Complete Procedure      $160.70
76945         Us Chornc Villus Sampling Img S&I                               $94.17
76945   26    Us Chornc Villus Sampling Img S&I                               $34.71
76945   TC    Us Chornc Villus Sampling Img S&I                               $59.46
76946         Us Amniocnts Img S&I                                            $79.28
76946   26    Us Amniocnts Img S&I                                            $19.54
76946   TC    Us Amniocnts Img S&I                                            $59.74
76947         Ultrasonic Guidance For Amniocentesis; Complete Procedure      $166.94
76947   TC    Ultrasonic Guidance For Amniocentesis; Complete Procedure      $116.86
76948         Us Aspir Ova Img S&I                                            $79.32
76948   26    Us Aspir Ova Img S&I                                            $19.55
76948   TC    Us Aspir Ova Img S&I                                            $59.77
76949         Ultrasonic Guidance For Aspiration Of Ova; Complete Procedur     $0.00
76949   TC    Ultrasonic Guidance For Aspiration Of Ova; Complete Procedur     $0.00
76950         Us Plmt Radj Ther Flds                                          $80.91
76950   26    Us Plmt Radj Ther Flds                                          $29.93
76950   TC    Us Plmt Radj Ther Flds                                          $50.98
76960         Ultrason Guidan Plcmt-Rad Therap                                $80.86
76960   26    Ultrason Guidan Plcmt-Rad Therap                                $24.26
76960   TC    Ultrason Guidan Plcmt-Rad Therap                                $56.60
76965         Us Ntrstl Radioelmnt Appl                                      $284.55
76965   26    Us Ntrstl Radioelmnt Appl                                       $67.81
76965   TC    Us Ntrstl Radioelmnt Appl                                      $216.74
76970         Us Std F-Up Spec                                                $61.64
76970   26    Us Std F-Up Spec                                                $20.30
76970   TC    Us Std F-Up Spec                                                $41.34
76975         Gi Ndsc Us S&I                                                 $101.67
76975   26    Gi Ndsc Us S&I                                                  $41.78
76975   TC    Gi Ndsc Us S&I                                                  $59.89
76977         Us B1 Dns Meas&Interpj Prph Sit Any Meth                        $35.35
76977   26    Us B1 Dns Meas&Interpj Prph Sit Any Meth                         $2.94
76977   TC    Us B1 Dns Meas&Interpj Prph Sit Any Meth                        $32.41
76980         Ultrsnd Xm Outside Reg Hrs                                     $118.30
76980   26    Ultrsnd Xm Outside Reg Hrs                                      $35.49
76980   TC    Ultrsnd Xm Outside Reg Hrs                                      $82.81
76986         Ultrasonic Guidance, Intraoperative                            $164.04
76986   26    Ultrasonic Guidance, Intraoperative                             $62.07
76986   TC    Ultrasonic Guidance, Intraoperative                            $101.97
76990         Spcl Ultrsnc Disply/Imagng Tecniques                            $81.90
76990   26    Spcl Ultrsnc Disply/Imagng Tecniques                            $24.57
76990   TC    Spcl Ultrsnc Disply/Imagng Tecniques                            $57.33
76991         Intraluminal Ultrasound Study (Eg, Transrectal, Transvaginal     $0.00

                                            Page 150
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                      Amount
76991    26   Intraluminal Ultrasound Study (Eg, Transrectal, Transvaginal       $0.00
76991   TC    Intraluminal Ultrasound Study (Eg, Transrectal, Transvaginal       $0.00
76999         Unlis Us Px                                                        $0.00
76999   26    Unlis Us Px                                                        $0.00
76999   TC    Unlis Us Px                                                        $0.00
77051         Computer-Aided Detection (Computer Algorithm Analysis Of Dig      $18.76
77052         Computer-Aided Detection (Computer Algorithm Analysis Of Dig      $18.76
77055         Mammography; Unilateral                                           $77.31
77056         Mammography; Bilateral                                            $95.39
77057         Screening Mammography, Bilateral (2-View Film Study Of Each       $83.93
77261         Ther Rad Tx Plnning Smpl                                          $73.37
77262         Ther Rad Tx Plnning Intrm                                        $110.65
77263         Ther Rad Tx Plnning Cplx                                        $164.65
77280         Ther Rad Simulaj-Aided Fld Setting Smpl                         $170.20
77280   26    Ther Rad Simulaj-Aided Fld Setting Smpl                           $35.37
77280   TC    Ther Rad Simulaj-Aided Fld Setting Smpl                         $134.83
77285         Ther Rad Simulaj-Aided Fld Setting Intrm                        $269.99
77285   26    Ther Rad Simulaj-Aided Fld Setting Intrm                          $53.05
77285   TC    Ther Rad Simulaj-Aided Fld Setting Intrm                        $216.94
77290         Ther Rad Simulaj-Aided Fld Setting Cplx                         $331.68
77290   26    Ther Rad Simulaj-Aided Fld Setting Cplx                           $78.14
77290   TC    Ther Rad Simulaj-Aided Fld Setting Cplx                         $253.54
77295         Ther Rad Simulaj-Aided Fld Setting 3-Dimensional               $1,315.94
77295   26    Ther Rad Simulaj-Aided Fld Setting 3-Dimensional                $229.37
77295   TC    Ther Rad Simulaj-Aided Fld Setting 3-Dimensional               $1,086.57
77299         Unlis Px Ther Rad Clinical Tx Plnning                              $0.00
77299   26    Unlis Px Ther Rad Clinical Tx Plnning                              $0.00
77299   TC    Unlis Px Ther Rad Clinical Tx Plnning                              $0.00
77300         Basic Radj Dosim Cal                                              $84.23
77300   26    Basic Radj Dosim Cal                                              $31.77
77300   TC    Basic Radj Dosim Cal                                              $52.46
77301         Ntsty Modul Radthx Pln Dose-Vol Histos                         $1,483.81
77301   26    Ntsty Modul Radthx Pln Dose-Vol Histos                          $396.18
77301   TC    Ntsty Modul Radthx Pln Dose-Vol Histos                         $1,087.63
77305         Telethx Isodose Pln Smpl                                        $108.92
77305   26    Telethx Isodose Pln Smpl                                          $35.81
77305   TC    Telethx Isodose Pln Smpl                                          $73.11
77310         Telethx Isodose Pln Intrm                                        $144.39
77310   26    Telethx Isodose Pln Intrm                                         $53.18
77310   TC    Telethx Isodose Pln Intrm                                         $91.21
77315         Telethx Isodose Pln Cplx                                        $181.82
77315   26    Telethx Isodose Pln Cplx                                          $78.35
77315   TC    Telethx Isodose Pln Cplx                                        $103.47
77321         Spec Telethx Port Pln Parts Hemibdy Tot Bdy                      $205.63
77321   26    Spec Telethx Port Pln Parts Hemibdy Tot Bdy                       $48.28
77321   TC    Spec Telethx Port Pln Parts Hemibdy Tot Bdy                      $157.35
77326         Brachytx Isodose Pln Smpl                                       $139.55
77326   26    Brachytx Isodose Pln Smpl                                         $47.25
77326   TC    Brachytx Isodose Pln Smpl                                         $92.30
77327         Brachytx Isodose Pln Intrm                                       $205.22
77327   26    Brachytx Isodose Pln Intrm                                        $70.12
77327   TC    Brachytx Isodose Pln Intrm                                       $135.10
77328         Brachytx Isodose Pln Cplx                                       $298.27
77328   26    Brachytx Isodose Pln Cplx                                       $105.59
77328   TC    Brachytx Isodose Pln Cplx                                       $192.68

                                            Page 151
                         MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
77331         Spec Dosim Only Prescribed Treating Phys                        $63.81
77331   26    Spec Dosim Only Prescribed Treating Phys                        $44.52
77331   TC    Spec Dosim Only Prescribed Treating Phys                        $19.29
77332         Tx Dev Design&Constj Smpl Smpl Blk Smpl Bolus                   $79.33
77332   26    Tx Dev Design&Constj Smpl Smpl Blk Smpl Bolus                   $26.93
77332   TC    Tx Dev Design&Constj Smpl Smpl Blk Smpl Bolus                   $52.40
77333         Tx Dev Design&Constj Intrm                                     $117.11
77333   26    Tx Dev Design&Constj Intrm                                      $42.85
77333   TC    Tx Dev Design&Constj Intrm                                      $74.26
77334         Tx Dev Design&Constj Cplx                                      $188.94
77334   26    Tx Dev Design&Constj Cplx                                       $62.37
77334   TC    Tx Dev Design&Constj Cplx                                      $126.57
77336         Continuing Medical Physics Consltj Pr Wk                       $115.69
77370         Spec Medical Radj Physics Consltj                              $135.13
77380         Proton Beam Delivery To A Single Treatment Area, Single Port     $0.00
77380   26    Proton Beam Delivery To A Single Treatment Area, Single Port     $0.00
77380   TC    Proton Beam Delivery To A Single Treatment Area, Single Port     $0.00
77381         Proton Beam Treatment To One-Two Treatment Areas, Two Or > P     $0.00
77381   26    Proton Beam Treatment To One-Two Treatment Areas, Two Or > P     $0.00
77381   TC    Proton Beam Treatment To One-Two Treatment Areas, Two Or > P     $0.00
77399         Unlis Medical Radj Dosim Tx Dev Spec Svcs                        $0.00
77399   26    Unlis Medical Radj Dosim Tx Dev Spec Svcs                        $0.00
77399   TC    Unlis Medical Radj Dosim Tx Dev Spec Svcs                        $0.00
77400         Daily Megavoltage Treatment Management; Simple                  $54.60
77401         Radj Dlvr Supfc&/Ortho Voltage                                  $69.48
77402         Radj Dlvr 1 Area 1/Prll Opsd Ports Smpl <5Mev                   $69.48
77403         Radj Dlvr 1 Area 1/Prll Opsd Ports Smpl 6-10Mev                 $69.48
77404         Radj Dlvr 1 Area 1/Prll Opsd Ports Smpl 11-19Mev                $69.48
77405         Daily Megavoltage Treatment Management; Intermediate            $65.52
77405   26    Daily Megavoltage Treatment Management; Intermediate            $19.66
77406         Radj Dlvr 1 Area 1/Prll Opsd Ports Smpl 20Mev/<                 $69.48
77406   26    Radj Dlvr 1 Area 1/Prll Opsd Ports Smpl 20Mev/<                 $20.84
77406   TC    Radj Dlvr 1 Area 1/Prll Opsd Ports Smpl 20Mev/<                 $48.64
77407         Radj Dlvr 2 Areas 3/>Ports 1 Mlt Blks <5Mev                     $81.20
77408         Radj Dlvr 2 Areas 3/>Ports 1 Mlt Blks 6-1Mev                    $81.20
77409         Radj Dlvr 2 Areas 3/>Ports 1 Mlt Blks 11-19Mev                  $81.20
77410         Daily Megavoltage Treatment Management; Complex                 $65.52
77411         Radj Dlvr 2 Areas 3/> Ports 1 Tx Area 20 Mev/<                  $81.20
77412         Radj Dlvr 3/> Areas Custom Blking <5Mev                         $90.74
77413         Radj Dlvr 3/> Areas Custom Blking 6-10Mev                       $90.74
77414         Radj Dlvr 3/> Areas Custom Blking 11-19Mev                      $90.74
77415         Therapeutic Radiology Treatment Port Film Interpretation And    $18.20
77416         Radj Dlvr 3/> Areas Custom Blking 20Mev/<                       $90.74
77417         Ther Rad Port Flm                                               $23.17
77418         Ntsty Modul Dlvr 1/Mlt Flds/Arcs Pr Tx Session                 $664.40
77418   26    Ntsty Modul Dlvr 1/Mlt Flds/Arcs Pr Tx Session                 $199.32
77418   TC    Ntsty Modul Dlvr 1/Mlt Flds/Arcs Pr Tx Session                 $465.08
77419         Weekly Radiation Therapy Management; Conformal                 $192.63
77420         Weekly Radiation Therapy Management; Simple                     $86.15
77421         Strsc X-Ray Gdn Loclzj Target Vol Dlvr Radj Ther               $150.85
77421   26    Strsc X-Ray Gdn Loclzj Target Vol Dlvr Radj Ther                $20.49
77421   TC    Strsc X-Ray Gdn Loclzj Target Vol Dlvr Radj Ther               $130.36
77422         Hi Nrg Neutron Radj Tx Dlvr 1 Tx Area                           $69.55
77423         Hi Nrg Neutron Radj Tx Dlvr 1/> Isocenter                       $90.23
77425         Weekly Radiation Therapy Management; Intermediate              $131.28

                                          Page 152
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                  Amount
77427         Radj Tx Mgmt 5 Txs                                           $168.85
77430         Weekly Radiation Therapy Management; Complex                 $192.63
77431         Radj Ther Mgmt Compl 1/2 Fxjs Only                            $95.67
77432         Strtctc Radj Tx Mgmt Cere Les                                $418.25
77465         Daily Kilovoltage Treatment Management                        $32.76
77470         Spec Tx Px                                                   $539.24
77470   26    Spec Tx Px                                                   $105.37
77470   TC    Spec Tx Px                                                   $433.87
77499         Unlis Ther Rad Tx Mgmt                                         $0.00
77499   26    Unlis Ther Rad Tx Mgmt                                         $0.00
77499   TC    Unlis Ther Rad Tx Mgmt                                         $0.00
77506         Rad.Treat.1 Area;Single Or Parallel Ports;20Mev Or Greater     $0.00
77506   26    Rad.Treat.1 Area;Single Or Parallel Ports;20Mev Or Greater     $0.00
77506   TC    Rad.Treat.1 Area;Single Or Parallel Ports;20Mev Or Greater     $0.00
77520         Proton Tx Dlvr Smpl W/O Compensation                           $0.00
77520   26    Proton Tx Dlvr Smpl W/O Compensation                           $0.00
77520   TC    Proton Tx Dlvr Smpl W/O Compensation                           $0.00
77522         Proton Tx Dlvr Smpl Compensation                               $0.00
77523         Proton Tx Dlvr Intrm                                           $0.00
77523   26    Proton Tx Dlvr Intrm                                           $0.00
77523   TC    Proton Tx Dlvr Intrm                                           $0.00
77525         Proton Tx Dlvr Cplx                                            $0.00
77600         Hyprthm Xtrnlly Gen Supfc                                    $198.46
77600   26    Hyprthm Xtrnlly Gen Supfc                                     $79.46
77600   TC    Hyprthm Xtrnlly Gen Supfc                                    $119.00
77605         Hyprthm Xtrnlly Gen Dp                                       $266.59
77605   26    Hyprthm Xtrnlly Gen Dp                                       $107.60
77605   TC    Hyprthm Xtrnlly Gen Dp                                       $158.99
77610         Hyprthm Gen Ntrstl Prb 5/Fewer                               $198.01
77610   26    Hyprthm Gen Ntrstl Prb 5/Fewer                                $79.07
77610   TC    Hyprthm Gen Ntrstl Prb 5/Fewer                               $118.94
77615         Hyprthm Gen Ntrstl Prb >5                                    $264.55
77615   26    Hyprthm Gen Ntrstl Prb >5                                    $105.66
77615   TC    Hyprthm Gen Ntrstl Prb >5                                    $158.89
77620         Hyprthm Gen Intrcv Prb                                       $197.97
77620   26    Hyprthm Gen Intrcv Prb                                        $79.05
77620   TC    Hyprthm Gen Intrcv Prb                                       $118.92
77630         Provision Extrnl Cmpnstng Shld;Radium Srcs                     $0.00
77635         Provision Extrnl Cmpnstng Shld;Radstpe Src                     $0.00
77699         Unlisted Proc Rad Therapy Trtment Aid                          $0.00
77700         Radium Therapy Dosimetry&Interp Applicatn                    $125.00
77705         Radioisotope Thrpy Dosmtry & Interp Applicatn                $125.00
77749         Unlisted Proc Internal Rad Dosimety                            $0.00
77750         Nfs/Instlj Radioelmnt Sln 3 Mo F-Up Care                     $300.61
77750   26    Nfs/Instlj Radioelmnt Sln 3 Mo F-Up Care                     $248.21
77750   TC    Nfs/Instlj Radioelmnt Sln 3 Mo F-Up Care                      $52.40
77755         Supervsn & Consult Radioelemnt Applctn Only                    $0.00
77760         Intracavity Radium Application                                 $0.00
77761         Intrcv Radj Src Appl Smpl                                    $287.50
77761   26    Intrcv Radj Src Appl Smpl                                    $188.83
77761   TC    Intrcv Radj Src Appl Smpl                                     $98.67
77762         Intrcv Radj Src Appl Intrm                                   $430.93
77762   26    Intrcv Radj Src Appl Intrm                                   $289.63
77762   TC    Intrcv Radj Src Appl Intrm                                   $141.30
77763         Intrcv Radj Src Appl Cplx                                    $609.30

                                            Page 153
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                     Amount
77763    26   Intrcv Radj Src Appl Cplx                      $433.76
77763   TC    Intrcv Radj Src Appl Cplx                      $175.54
77765         Intracavitry Radioisotope Application             $0.00
77770         Interstitial Radium Application                   $0.00
77775         Interstitial Radioisotope Therapy                 $0.00
77776         Ntrstl Radj Src Appl Smpl                      $305.37
77776   26    Ntrstl Radj Src Appl Smpl                      $219.44
77776   TC    Ntrstl Radj Src Appl Smpl                        $85.93
77777         Ntrstl Radj Src Appl Intrm                     $545.11
77777   26    Ntrstl Radj Src Appl Intrm                     $379.23
77777   TC    Ntrstl Radj Src Appl Intrm                     $165.88
77778         Ntrstl Radj Src Appl Cplx                      $768.57
77778   26    Ntrstl Radj Src Appl Cplx                      $567.36
77778   TC    Ntrstl Radj Src Appl Cplx                      $201.21
77780         Radium Handling & Looding                      $500.00
77781         Remote Aftld Hi Ntsty Brachytx 1-4 Src         $871.92
77781   26    Remote Aftld Hi Ntsty Brachytx 1-4 Src           $83.44
77781   TC    Remote Aftld Hi Ntsty Brachytx 1-4 Src         $788.48
77782         Remote Aftld Hi Ntsty Brachytx 5-8 Src         $914.40
77782   26    Remote Aftld Hi Ntsty Brachytx 5-8 Src         $125.46
77782   TC    Remote Aftld Hi Ntsty Brachytx 5-8 Src         $788.94
77783         Remote Aftld Hi Ntsty Brachytx 9-12 Src        $976.64
77783   26    Remote Aftld Hi Ntsty Brachytx 9-12 Src        $187.12
77783   TC    Remote Aftld Hi Ntsty Brachytx 9-12 Src        $789.52
77784         Remote Aftld Hi Ntsty Brachytx >12 Src        $1,072.41
77784   26    Remote Aftld Hi Ntsty Brachytx >12 Src         $282.04
77784   TC    Remote Aftld Hi Ntsty Brachytx >12 Src         $790.37
77785         Radioisotope Handling & Loading                $500.00
77789         Surf Appl Radj Src                               $74.20
77789   26    Surf Appl Radj Src                               $56.76
77789   TC    Surf Appl Radj Src                               $17.44
77790         Supvj Handling Loading Radj Src                  $72.73
77790   26    Supvj Handling Loading Radj Src                  $53.43
77790   TC    Supvj Handling Loading Radj Src                  $19.30
77799         Unlis Clinical Brachytx                           $0.00
77799   26    Unlis Clinical Brachytx                           $0.00
77799   TC    Unlis Clinical Brachytx                           $0.00
78000         Thyr Uptk 1 Deter                                $47.92
78000   26    Thyr Uptk 1 Deter                                 $9.95
78000   TC    Thyr Uptk 1 Deter                                $37.97
78001         Thyr Uptk Mlt Deters                             $64.09
78001   26    Thyr Uptk Mlt Deters                             $13.26
78001   TC    Thyr Uptk Mlt Deters                             $50.83
78003         Thyr Uptk Stimj Suprj/Dschrg X 1St Uptk Std      $54.61
78003   26    Thyr Uptk Stimj Suprj/Dschrg X 1St Uptk Std      $16.61
78003   TC    Thyr Uptk Stimj Suprj/Dschrg X 1St Uptk Std      $38.00
78006         Thyr Img Uptk 1 Deter                          $117.88
78006   26    Thyr Img Uptk 1 Deter                            $25.05
78006   TC    Thyr Img Uptk 1 Deter                            $92.83
78007         Thyr Img Uptk Mlt Deters                       $125.96
78007   26    Thyr Img Uptk Mlt Deters                         $25.42
78007   TC    Thyr Img Uptk Mlt Deters                       $100.54
78010         Thyr Img Only                                    $91.42
78010   26    Thyr Img Only                                    $19.90
78010   TC    Thyr Img Only                                    $71.52

                                             Page 154
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                  Amount
78011         Thyr Img Vasc Flo                            $116.75
78011   26    Thyr Img Vasc Flo                             $22.84
78011   TC    Thyr Img Vasc Flo                             $93.91
78015         Thyr Carc Metastases Img Lmtd Area           $135.32
78015   26    Thyr Carc Metastases Img Lmtd Area            $34.66
78015   TC    Thyr Carc Metastases Img Lmtd Area           $100.66
78016         Thyr Carc Metastases Img Addl Std            $177.60
78016   26    Thyr Carc Metastases Img Addl Std             $42.38
78016   TC    Thyr Carc Metastases Img Addl Std            $135.22
78017         Thyroid Carcinoma Imaging; Multiple Areas    $183.15
78017   26    Thyroid Carcinoma Imaging; Multiple Areas     $54.95
78017   TC    Thyroid Carcinoma Imaging; Multiple Areas    $128.21
78018         Thyr Carc Metastases Img Whbdy               $255.51
78018   26    Thyr Carc Metastases Img Whbdy                $44.18
78018   TC    Thyr Carc Metastases Img Whbdy               $211.33
78020         Thyr Carc Metastases Uptk                     $84.42
78020   26    Thyr Carc Metastases Uptk                     $30.73
78020   TC    Thyr Carc Metastases Uptk                     $53.69
78070         Parathyr Img                                 $113.77
78070   26    Parathyr Img                                  $42.11
78070   TC    Parathyr Img                                  $71.66
78075         Adrnl Img Cortex&/Medulla                    $249.93
78075   26    Adrnl Img Cortex&/Medulla                     $38.64
78075   TC    Adrnl Img Cortex&/Medulla                    $211.29
78099         Unlis Endoc Px Dx Nuc Med                      $0.00
78099   26    Unlis Endoc Px Dx Nuc Med                      $0.00
78099   TC    Unlis Endoc Px Dx Nuc Med                      $0.00
78102         B1 Marrow Img Lmtd Area                      $108.03
78102   26    B1 Marrow Img Lmtd Area                       $28.39
78102   TC    B1 Marrow Img Lmtd Area                       $79.64
78103         B1 Marrow Img Mlt Areas                      $162.16
78103   26    B1 Marrow Img Mlt Areas                       $38.69
78103   TC    B1 Marrow Img Mlt Areas                      $123.47
78104         B1 Marrow Img Whbdy                          $199.66
78104   26    B1 Marrow Img Whbdy                           $40.89
78104   TC    B1 Marrow Img Whbdy                          $158.77
78110         Plsm Vol Rp Vol-Dil Tq Spx 1 Sampling         $47.19
78110   26    Plsm Vol Rp Vol-Dil Tq Spx 1 Sampling          $9.95
78110   TC    Plsm Vol Rp Vol-Dil Tq Spx 1 Sampling         $37.24
78111         Plsm Vol Rp Vol-Dil Tq Spx Mlt Samplings     $111.82
78111   26    Plsm Vol Rp Vol-Dil Tq Spx Mlt Samplings      $11.41
78111   TC    Plsm Vol Rp Vol-Dil Tq Spx Mlt Samplings     $100.41
78120         Rbc Vol Deter Spx 1 Sampling                  $79.93
78120   26    Rbc Vol Deter Spx 1 Sampling                  $11.79
78120   TC    Rbc Vol Deter Spx 1 Sampling                  $68.14
78121         Rbc Vol Deter Spx Mlt Samplings              $128.70
78121   26    Rbc Vol Deter Spx Mlt Samplings               $16.18
78121   TC    Rbc Vol Deter Spx Mlt Samplings              $112.52
78122         Whl Bld Vol Deter Rp Vol-Dil Tq              $201.93
78122   26    Whl Bld Vol Deter Rp Vol-Dil Tq               $23.18
78122   TC    Whl Bld Vol Deter Rp Vol-Dil Tq              $178.75
78130         Rbc Surv Std                                 $142.21
78130   26    Rbc Surv Std                                  $31.68
78130   TC    Rbc Surv Std                                 $110.53
78135         Rbc Surv Std Diffial Organ/Tiss Kin          $222.29

                                            Page 155
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                            Amount
78135    26   Rbc Surv Std Diffial Organ/Tiss Kin                     $33.12
78135   TC    Rbc Surv Std Diffial Organ/Tiss Kin                    $189.17
78140         Lbld Rbc Sqsj Diffial Organ/Tiss                       $184.49
78140   26    Lbld Rbc Sqsj Diffial Organ/Tiss                        $31.31
78140   TC    Lbld Rbc Sqsj Diffial Organ/Tiss                       $153.18
78160         Plasma Radioiron Disappearance (Turnover) Rate         $160.44
78160   26    Plasma Radioiron Disappearance (Turnover) Rate          $18.03
78160   TC    Plasma Radioiron Disappearance (Turnover) Rate         $142.41
78162         Radioiron Oral Absorption                              $148.28
78162   26    Radioiron Oral Absorption                               $23.92
78162   TC    Radioiron Oral Absorption                              $124.36
78170         Radioiron Red Cell Utilization                         $228.48
78170   26    Radioiron Red Cell Utilization                          $22.07
78170   TC    Radioiron Red Cell Utilization                         $206.41
78172         Chelatable Iron For Estimation Of Total Body Iron       $28.00
78172   26    Chelatable Iron For Estimation Of Total Body Iron       $27.18
78172   TC    Chelatable Iron For Estimation Of Total Body Iron        $0.00
78180         Radioiron Body Distribution/Stdrag Pools               $109.20
78180   26    Radioiron Body Distribution/Stdrag Pools                $32.76
78180   TC    Radioiron Body Distribution/Stdrag Pools                $76.44
78185         Spleen Img Only +-Vasc Flo                             $112.69
78185   26    Spleen Img Only +-Vasc Flo                              $20.62
78185   TC    Spleen Img Only +-Vasc Flo                              $92.07
78186         Spleen Imaging Only; With Vascular Flow                $130.87
78186   26    Spleen Imaging Only; With Vascular Flow                 $39.26
78186   TC    Spleen Imaging Only; With Vascular Flow                 $91.61
78190         Kin Std Pltlt Surv +-Diffial Organ/Tiss Loclzj         $279.23
78190   26    Kin Std Pltlt Surv +-Diffial Organ/Tiss Loclzj          $57.10
78190   TC    Kin Std Pltlt Surv +-Diffial Organ/Tiss Loclzj         $222.13
78191         Pltlt Surv Std                                         $315.52
78191   26    Pltlt Surv Std                                          $31.27
78191   TC    Pltlt Surv Std                                         $284.25
78192         White Blood Cell Localization; Limited Area Scanning   $151.64
78192   26    White Blood Cell Localization; Limited Area Scanning    $45.49
78192   TC    White Blood Cell Localization; Limited Area Scanning   $106.15
78193         White Blood Cell Localization; Whole Body              $365.94
78193   26    White Blood Cell Localization; Whole Body              $109.78
78193   TC    White Blood Cell Localization; Whole Body              $256.16
78195         Lymphatics&Lymph Nod Img                               $220.52
78195   26    Lymphatics&Lymph Nod Img                                $61.59
78195   TC    Lymphatics&Lymph Nod Img                               $158.93
78199         Unlis Hematop Ret/Endo&Lymphatic Dx Nuc Med              $0.00
78199   26    Unlis Hematop Ret/Endo&Lymphatic Dx Nuc Med              $0.00
78199   TC    Unlis Hematop Ret/Endo&Lymphatic Dx Nuc Med              $0.00
78201         Lvr Img Static Only                                    $114.55
78201   26    Lvr Img Static Only                                     $22.46
78201   TC    Lvr Img Static Only                                     $92.09
78202         Lvr Img Vasc Flo                                       $137.66
78202   26    Lvr Img Vasc Flo                                        $26.13
78202   TC    Lvr Img Vasc Flo                                       $111.53
78205         Lvr Img Spect                                          $266.42
78205   26    Lvr Img Spect                                           $36.79
78205   TC    Lvr Img Spect                                          $229.63
78206         Lvr Img Spect Vasc Flo                                 $271.31
78206   26    Lvr Img Spect Vasc Flo                                  $49.57

                                             Page 156
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                         Amount
78206   TC    Lvr Img Spect Vasc Flo                              $221.74
78215         Lvr&Spleen Img Static Only                          $138.74
78215   26    Lvr&Spleen Img Static Only                           $25.03
78215   TC    Lvr&Spleen Img Static Only                          $113.71
78216         Lvr&Spleen Img Vasc Flo                             $164.17
78216   26    Lvr&Spleen Img Vasc Flo                              $29.07
78216   TC    Lvr&Spleen Img Vasc Flo                             $135.10
78220         Lvr Funcj Std Hepatbl Agt Srl Images                $169.62
78220   26    Lvr Funcj Std Hepatbl Agt Srl Images                 $25.02
78220   TC    Lvr Funcj Std Hepatbl Agt Srl Images                $144.60
78221         Liver Fnctn Study W/Heptblry Agents;W/Probe Tech     $59.15
78221   26    Liver Fnctn Study W/Heptblry Agents;W/Probe Tech     $17.75
78221   TC    Liver Fnctn Study W/Heptblry Agents;W/Probe Tech     $41.41
78223         Hepatbl Dux Sys Img Glbldr                          $185.73
78223   26    Hepatbl Dux Sys Img Glbldr                           $43.11
78223   TC    Hepatbl Dux Sys Img Glbldr                          $142.62
78225         Liver-Lung Imaging (Eg, Subphrenic Abscess)         $172.99
78225   26    Liver-Lung Imaging (Eg, Subphrenic Abscess)          $51.90
78225   TC    Liver-Lung Imaging (Eg, Subphrenic Abscess)         $121.09
78230         Salivary Glnd Img                                   $107.99
78230   26    Salivary Glnd Img                                    $22.85
78230   TC    Salivary Glnd Img                                    $85.14
78231         Salivary Glnd Img Srl Images                        $150.21
78231   26    Salivary Glnd Img Srl Images                         $26.87
78231   TC    Salivary Glnd Img Srl Images                        $123.34
78232         Salivary Glnd Funcj Std                             $161.12
78232   26    Salivary Glnd Funcj Std                              $23.91
78232   TC    Salivary Glnd Funcj Std                             $137.21
78240         Pancreas Imaging                                    $209.30
78240   26    Pancreas Imaging                                     $62.79
78240   TC    Pancreas Imaging                                    $146.51
78258         Esophgl Motility                                    $149.62
78258   26    Esophgl Motility                                     $37.96
78258   TC    Esophgl Motility                                    $111.66
78261         Gstr Mucosa Img                                     $195.55
78261   26    Gstr Mucosa Img                                      $36.10
78261   TC    Gstr Mucosa Img                                     $159.45
78262         G-Esop Rflx Std                                     $200.66
78262   26    G-Esop Rflx Std                                      $35.34
78262   TC    G-Esop Rflx Std                                     $165.32
78264         Gstr Emptying Std                                   $200.74
78264   26    Gstr Emptying Std                                    $40.15
78264   TC    Gstr Emptying Std                                   $160.59
78267         Urea Brth Tst C-14 Isotopic Acquisj Alys             $10.98
78268         Urea Brth Tst C-14 Isotopic Alys                     $94.11
78270         Vit B-12 Absrpj Std W/O Intrnsc Factor               $71.10
78270   26    Vit B-12 Absrpj Std W/O Intrnsc Factor               $10.32
78270   TC    Vit B-12 Absrpj Std W/O Intrnsc Factor               $60.78
78271         Vit B-12 Absrpj Std Intrnsc Factor                   $74.75
78271   26    Vit B-12 Absrpj Std Intrnsc Factor                   $10.31
78271   TC    Vit B-12 Absrpj Std Intrnsc Factor                   $64.44
78272         Vit B-12 Absrpj Std Cmbn W/&W/O Intrnsc Factor      $104.51
78272   26    Vit B-12 Absrpj Std Cmbn W/&W/O Intrnsc Factor       $13.98
78272   TC    Vit B-12 Absrpj Std Cmbn W/&W/O Intrnsc Factor       $90.53
78276         Gastrointestinal Aspirate Blood Loss Localization   $141.10

                                            Page 157
                           MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                              Amount
78276    26   Gastrointestinal Aspirate Blood Loss Localization         $42.33
78276   TC    Gastrointestinal Aspirate Blood Loss Localization         $98.77
78278         Aqt Gi Bld Loss Img                                      $240.15
78278   26    Aqt Gi Bld Loss Img                                       $50.84
78278   TC    Aqt Gi Bld Loss Img                                      $189.31
78280         Gastrointestinal Blood Loss Study (Eg, Stool Counting)   $126.21
78280   26    Gastrointestinal Blood Loss Study (Eg, Stool Counting)    $37.86
78280   TC    Gastrointestinal Blood Loss Study (Eg, Stool Counting)    $88.35
78282         Gi Protein Loss                                           $19.61
78282   26    Gi Protein Loss                                           $19.75
78282   TC    Gi Protein Loss                                            $0.00
78285         Gastrointstnal Fat Absorption Stdy                        $72.80
78285   26    Gastrointstnal Fat Absorption Stdy                        $21.84
78285   TC    Gastrointstnal Fat Absorption Stdy                        $50.96
78286         Gastrointstnal Fatty Acid Absorpton Stdy                  $72.80
78286   26    Gastrointstnal Fatty Acid Absorpton Stdy                  $21.84
78286   TC    Gastrointstnal Fatty Acid Absorpton Stdy                  $50.96
78290         Int Img                                                  $153.67
78290   26    Int Img                                                   $35.01
78290   TC    Int Img                                                  $118.66
78291         Prtl-Ven Shunt Patency Tst                               $164.83
78291   26    Prtl-Ven Shunt Patency Tst                                $45.36
78291   TC    Prtl-Ven Shunt Patency Tst                               $119.47
78299         Unlis Gi Px Dx Nuc Med                                     $0.00
78299   26    Unlis Gi Px Dx Nuc Med                                     $0.00
78299   TC    Unlis Gi Px Dx Nuc Med                                     $0.00
78300         B1&/Jt Img Lmtd Area                                     $129.43
78300   26    B1&/Jt Img Lmtd Area                                      $32.09
78300   TC    B1&/Jt Img Lmtd Area                                      $97.34
78305         B1&/Jt Img Mlt Areas                                     $184.95
78305   26    B1&/Jt Img Mlt Areas                                      $42.37
78305   TC    B1&/Jt Img Mlt Areas                                     $142.58
78306         B1&/Jt Img Whbdy                                         $210.34
78306   26    B1&/Jt Img Whbdy                                          $44.21
78306   TC    B1&/Jt Img Whbdy                                         $166.13
78310         Bone And/Or Joint Imaging; Vascular Flow Only             $66.05
78310   26    Bone And/Or Joint Imaging; Vascular Flow Only             $19.82
78310   TC    Bone And/Or Joint Imaging; Vascular Flow Only             $46.24
78315         B1&/Jt Img 3 Phase Std                                   $238.35
78315   26    B1&/Jt Img 3 Phase Std                                    $52.32
78315   TC    B1&/Jt Img 3 Phase Std                                   $186.03
78320         B1&/Jt Img Tomog Spect                                   $283.53
78320   26    B1&/Jt Img Tomog Spect                                    $53.76
78320   TC    B1&/Jt Img Tomog Spect                                   $229.77
78350         B1 Dns Std 1+ Sits 1 Phtn Absrptm                         $40.96
78350   26    B1 Dns Std 1+ Sits 1 Phtn Absrptm                         $11.07
78350   TC    B1 Dns Std 1+ Sits 1 Phtn Absrptm                         $29.89
78351         B1 Dns Std 1+ Sits Dual Phtn Absrptm 1+ Sits              $74.42
78351   26    B1 Dns Std 1+ Sits Dual Phtn Absrptm 1+ Sits              $22.33
78351   TC    B1 Dns Std 1+ Sits Dual Phtn Absrptm 1+ Sits              $52.09
78380         Joint Imaging; Limited Area                               $75.53
78380   26    Joint Imaging; Limited Area                               $22.66
78380   TC    Joint Imaging; Limited Area                               $52.87
78381         Joint Imaging; Multiple Areas                            $144.68
78381   26    Joint Imaging; Multiple Areas                             $43.40

                                             Page 158
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
78381   TC    Joint Imaging; Multiple Areas                                  $101.28
78399         Unlis Muscskel Px Dx Nuc Med                                     $0.00
78399   26    Unlis Muscskel Px Dx Nuc Med                                     $0.00
78399   TC    Unlis Muscskel Px Dx Nuc Med                                     $0.00
78401         Cardiac Blood Pool Imaging                                     $118.30
78402         Cardiac Blood Pool Imaging, With Vascular Flow Assessment      $170.17
78403         Cardiac Blood Pool Imaging By Gated Equilibrium Blood          $118.30
78404         Cardiac Blood Pool Imaging By Gated Equilibrium Blood          $209.30
78407         Cardiac Blood Pool Imaging By Gated Equilibrium Blood          $163.80
78409         Crdc Bld Pool Imgng; W/Dtrmntn Of Vntrclr Ejctn Fr             $118.30
78411         Cardiac Blood Pool Imaging By First Pass Technique,            $118.30
78412         Cardiac Blood Pool Imaging By First Pass Technique,            $209.30
78413         Crdc Bld Pool Imgn; W/Dtrmntn Of Vntrclr Wall                  $118.30
78414         Deter Ctr C-V Hemodyn Non-Img +-Rx 1/Mlt                        $24.02
78414   26    Deter Ctr C-V Hemodyn Non-Img +-Rx 1/Mlt                        $23.46
78414   TC    Deter Ctr C-V Hemodyn Non-Img +-Rx 1/Mlt                         $0.00
78415         Cardiac Blood Pool Imaging, Functional Imaging (Eg, Phase An    $69.94
78415   26    Cardiac Blood Pool Imaging, Functional Imaging (Eg, Phase An    $20.98
78415   TC    Cardiac Blood Pool Imaging, Functional Imaging (Eg, Phase An    $48.96
78418         Myocardium Imaging,                                            $118.30
78418   26    Myocardium Imaging,                                             $35.49
78418   TC    Myocardium Imaging,                                             $82.81
78424         Myocardium Imaging;                                            $250.00
78424   26    Myocardium Imaging;                                             $75.00
78424   TC    Myocardium Imaging;                                            $175.00
78425         Cardiac Regurgitant Index                                      $221.26
78425   26    Cardiac Regurgitant Index                                       $66.38
78425   TC    Cardiac Regurgitant Index                                      $154.88
78428         Car Shunt Detcj                                                $129.52
78428   26    Car Shunt Detcj                                                 $41.33
78428   TC    Car Shunt Detcj                                                 $88.19
78435         Cardiac Flow Imaging (Ie, Angiocardiography)                    $30.03
78435   26    Cardiac Flow Imaging (Ie, Angiocardiography)                     $9.01
78435   TC    Cardiac Flow Imaging (Ie, Angiocardiography)                    $21.02
78445         Non-Car Vasc Flo Img                                            $98.08
78445   26    Non-Car Vasc Flo Img                                            $25.07
78445   TC    Non-Car Vasc Flo Img                                            $73.01
78455         Venous Thrombosis Study (Eg, Radioactive Fibrinogen)           $192.62
78455   26    Venous Thrombosis Study (Eg, Radioactive Fibrinogen)            $37.56
78455   TC    Venous Thrombosis Study (Eg, Radioactive Fibrinogen)           $155.06
78456         Aqt Ven Thrombosis Img Peptide                                 $210.02
78456   26    Aqt Ven Thrombosis Img Peptide                                  $51.66
78456   TC    Aqt Ven Thrombosis Img Peptide                                 $158.36
78457         Ven Thrombosis Img Venogram Uni                                $142.70
78457   26    Ven Thrombosis Img Venogram Uni                                 $39.46
78457   TC    Ven Thrombosis Img Venogram Uni                                $103.24
78458         Ven Thrombosis Img Venogram Bi                                 $203.35
78458   26    Ven Thrombosis Img Venogram Bi                                  $46.79
78458   TC    Ven Thrombosis Img Venogram Bi                                 $156.56
78459         Myocrd Img P+ Emij Tomog Metab Eval                              $0.00
78459   26    Myocrd Img P+ Emij Tomog Metab Eval                             $78.86
78459   TC    Myocrd Img P+ Emij Tomog Metab Eval                              $0.00
78460         Myocrd Prfuj Img Plnr 1 Std Rest/Strs                          $136.53
78460   26    Myocrd Prfuj Img Plnr 1 Std Rest/Strs                           $44.28
78460   TC    Myocrd Prfuj Img Plnr 1 Std Rest/Strs                           $92.25

                                            Page 159
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
78461         Myocrd Prfuj Img Mlt Std Plnr                                  $247.33
78461   26    Myocrd Prfuj Img Mlt Std Plnr                                   $63.39
78461   TC    Myocrd Prfuj Img Mlt Std Plnr                                  $183.94
78464         Myocrd Prfuj Img Tomog Spect 1 Std                             $330.93
78464   26    Myocrd Prfuj Img Tomog Spect 1 Std                              $55.96
78464   TC    Myocrd Prfuj Img Tomog Spect 1 Std                             $274.97
78465         Myocrd Prfuj Img Tomog Spect Mlt Std                           $533.16
78465   26    Myocrd Prfuj Img Tomog Spect Mlt Std                            $75.07
78465   TC    Myocrd Prfuj Img Tomog Spect Mlt Std                           $458.09
78466         Myocrd Img Infarct Avid Plnr Qual/Quan                         $137.89
78466   26    Myocrd Img Infarct Avid Plnr Qual/Quan                          $36.13
78466   TC    Myocrd Img Infarct Avid Plnr Qual/Quan                         $101.76
78467         Myocardial Imaging, Infarct Avid, At Rest; Quantitative         $91.00
78467   26    Myocardial Imaging, Infarct Avid, At Rest; Quantitative         $27.30
78467   TC    Myocardial Imaging, Infarct Avid, At Rest; Quantitative         $63.70
78468         Myocrd Img Infarct Avid Plnr Ejec Fxj 1St Ps Tq                $183.83
78468   26    Myocrd Img Infarct Avid Plnr Ejec Fxj 1St Ps Tq                 $41.25
78468   TC    Myocrd Img Infarct Avid Plnr Ejec Fxj 1St Ps Tq                $142.58
78469         Myocrd Img Infarct Avid Plnr Tomog Spect +-Quan                $250.40
78469   26    Myocrd Img Infarct Avid Plnr Tomog Spect +-Quan                 $47.13
78469   TC    Myocrd Img Infarct Avid Plnr Tomog Spect +-Quan                $203.27
78470         Cardiac Output                                                  $91.00
78470   26    Cardiac Output                                                  $27.30
78470   TC    Cardiac Output                                                  $63.70
78471         Cardiac Blood Pool Imaging, Gated Equilibrium, At Rest, Wall   $233.92
78471   26    Cardiac Blood Pool Imaging, Gated Equilibrium, At Rest, Wall    $70.18
78471   TC    Cardiac Blood Pool Imaging, Gated Equilibrium, At Rest, Wall   $163.74
78472         Card Bpi Gtd =Brm Plnr 1 Std Rest/Strs                         $265.55
78472   26    Card Bpi Gtd =Brm Plnr 1 Std Rest/Strs                          $50.83
78472   TC    Card Bpi Gtd =Brm Plnr 1 Std Rest/Strs                         $214.72
78473         Card Bpi Gtd =Brm Mlt Std Wall Motion Std                      $395.76
78473   26    Card Bpi Gtd =Brm Mlt Std Wall Motion Std                       $75.12
78473   TC    Card Bpi Gtd =Brm Mlt Std Wall Motion Std                      $320.64
78474         Cardiac Blood Pool Imaging, Gated Equilibrium, At Rest; Quan   $505.80
78474   26    Cardiac Blood Pool Imaging, Gated Equilibrium, At Rest; Quan   $151.74
78474   TC    Cardiac Blood Pool Imaging, Gated Equilibrium, At Rest; Quan   $354.06
78475         Cardiac Blood Pool Imaging, Gated Equilibrium, At Rest; Quan     $0.00
78475   26    Cardiac Blood Pool Imaging, Gated Equilibrium, At Rest; Quan     $0.00
78475   TC    Cardiac Blood Pool Imaging, Gated Equilibrium, At Rest; Quan     $0.00
78476         Cardiac Blood Pool Imaging, Gated Equilibrium, At Rest; Quan     $0.00
78476   26    Cardiac Blood Pool Imaging, Gated Equilibrium, At Rest; Quan     $0.00
78476   TC    Cardiac Blood Pool Imaging, Gated Equilibrium, At Rest; Quan     $0.00
78477         Cardiac Blood Pool Imaging, Gated Equilibrium, At Rest; Quan   $527.75
78477   26    Cardiac Blood Pool Imaging, Gated Equilibrium, At Rest; Quan   $158.33
78477   TC    Cardiac Blood Pool Imaging, Gated Equilibrium, At Rest; Quan   $369.43
78478         Myocrd Prfuj Std Wall Motion Qual/Quan Std                      $93.40
78478   26    Myocrd Prfuj Std Wall Motion Qual/Quan Std                      $32.12
78478   TC    Myocrd Prfuj Std Wall Motion Qual/Quan Std                      $61.28
78479         Cardiac Blood Pool Imaging, Gated Equilibrium, At Rest; Seri     $0.00
78479   26    Cardiac Blood Pool Imaging, Gated Equilibrium, At Rest; Seri     $0.00
78479   TC    Cardiac Blood Pool Imaging, Gated Equilibrium, At Rest; Seri     $0.00
78480         Myocrd Prfuj Std Ejec Fxj                                       $93.40
78480   26    Myocrd Prfuj Std Ejec Fxj                                       $32.12
78480   TC    Myocrd Prfuj Std Ejec Fxj                                       $61.28
78481         Card Bpi Plnr 1St Ps 1 Std Plus Ejec Fxj                       $254.47

                                            Page 160
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
78481    26   Card Bpi Plnr 1St Ps 1 Std Plus Ejec Fxj                        $51.20
78481   TC    Card Bpi Plnr 1St Ps 1 Std Plus Ejec Fxj                       $203.27
78483         Card Bpi Plnr 1St Ps Mlt Std Plus Ejec Fxj                     $381.84
78483   26    Card Bpi Plnr 1St Ps Mlt Std Plus Ejec Fxj                      $76.22
78483   TC    Card Bpi Plnr 1St Ps Mlt Std Plus Ejec Fxj                     $305.62
78484         Cardiac Blood Pool Imaging, First Pass Technique, At Rest; Q     $0.00
78484   26    Cardiac Blood Pool Imaging, First Pass Technique, At Rest; Q     $0.00
78484   TC    Cardiac Blood Pool Imaging, First Pass Technique, At Rest; Q     $0.00
78485         Cardiac Blood Pool Imaging, First Pass Technique, At Rest; Q     $0.00
78485   26    Cardiac Blood Pool Imaging, First Pass Technique, At Rest; Q     $0.00
78485   TC    Cardiac Blood Pool Imaging, First Pass Technique, At Rest; Q     $0.00
78486         Cardiac Blood Pool Imaging, First Pass Technique, At Rest; Q     $0.00
78486   26    Cardiac Blood Pool Imaging, First Pass Technique, At Rest; Q     $0.00
78486   TC    Cardiac Blood Pool Imaging, First Pass Technique, At Rest; Q     $0.00
78487         Cardiac Blood Pool Imaging, First Pass Technique, At Rest; Q     $0.00
78487   26    Cardiac Blood Pool Imaging, First Pass Technique, At Rest; Q     $0.00
78487   TC    Cardiac Blood Pool Imaging, First Pass Technique, At Rest; Q     $0.00
78489         Cardiac Blood Pool Imaging, First Pass Technique, At Rest; S     $0.00
78489   26    Cardiac Blood Pool Imaging, First Pass Technique, At Rest; S     $0.00
78489   TC    Cardiac Blood Pool Imaging, First Pass Technique, At Rest; S     $0.00
78490         Tissue Clearance Exams                                           $0.00
78490   26    Tissue Clearance Exams                                           $0.00
78490   TC    Tissue Clearance Exams                                           $0.00
78491         Myocrd Img P+ Emij Tomog Prfuj 1 Std                             $0.00
78491   26    Myocrd Img P+ Emij Tomog Prfuj 1 Std                            $79.99
78491   TC    Myocrd Img P+ Emij Tomog Prfuj 1 Std                             $0.00
78492         Myocrd Img P+ Emij Tomog Prfuj Mlt Std                           $0.00
78492   26    Myocrd Img P+ Emij Tomog Prfuj Mlt Std                          $99.69
78492   TC    Myocrd Img P+ Emij Tomog Prfuj Mlt Std                           $0.00
78494         Card Bpi Gtd =Brm Spect Rest Wall Motion                       $332.91
78494   26    Card Bpi Gtd =Brm Spect Rest Wall Motion                        $60.69
78494   TC    Card Bpi Gtd =Brm Spect Rest Wall Motion                       $272.22
78496         Card Bpi Gtd =Brm 1 Std Rest R Ventr Ejec Fxj                  $297.53
78496   26    Card Bpi Gtd =Brm 1 Std Rest R Ventr Ejec Fxj                   $25.71
78496   TC    Card Bpi Gtd =Brm 1 Std Rest R Ventr Ejec Fxj                  $271.82
78499         Unlis Cv Dx Nuc Med                                              $0.00
78499   26    Unlis Cv Dx Nuc Med                                              $0.00
78499   TC    Unlis Cv Dx Nuc Med                                              $0.00
78580         Pulm Pi Part                                                   $171.33
78580   26    Pulm Pi Part                                                    $37.95
78580   TC    Pulm Pi Part                                                   $133.38
78581         Pulmonary Perfusion Imaging; Gaseous                           $113.50
78581   26    Pulmonary Perfusion Imaging; Gaseous                            $34.05
78581   TC    Pulmonary Perfusion Imaging; Gaseous                            $79.45
78582         Pulmonary Perfusion Imaging; Gaseous, With Ventilation, Rebr   $169.94
78582   26    Pulmonary Perfusion Imaging; Gaseous, With Ventilation, Rebr    $50.98
78582   TC    Pulmonary Perfusion Imaging; Gaseous, With Ventilation, Rebr   $118.96
78584         Pulm Pi Part Vntj 1 Brth                                       $175.18
78584   26    Pulm Pi Part Vntj 1 Brth                                        $50.52
78584   TC    Pulm Pi Part Vntj 1 Brth                                       $124.66
78585         Pulm Pi Part Vntj Rbrthing&Wshot +-1 Brth                      $275.18
78585   26    Pulm Pi Part Vntj Rbrthing&Wshot +-1 Brth                       $56.00
78585   TC    Pulm Pi Part Vntj Rbrthing&Wshot +-1 Brth                      $219.18
78586         Pulm Vi Aersl 1 Projection                                     $121.14
78586   26    Pulm Vi Aersl 1 Projection                                      $20.25

                                            Page 161
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                  Amount
78586   TC    Pulm Vi Aersl 1 Projection                   $100.89
78587         Pulm Vi Aersl Mlt Prjcj                      $133.62
78587   26    Pulm Vi Aersl Mlt Prjcj                       $25.03
78587   TC    Pulm Vi Aersl Mlt Prjcj                      $108.59
78588         Pulm Pi Part Vntj Img Aersl 1/Mlt Prjcj      $181.19
78588   26    Pulm Pi Part Vntj Img Aersl 1/Mlt Prjcj       $56.10
78588   TC    Pulm Pi Part Vntj Img Aersl 1/Mlt Prjcj      $125.09
78591         Pulm Vi Gaseous 1 Prjcj                      $130.99
78591   26    Pulm Vi Gaseous 1 Prjcj                       $20.60
78591   TC    Pulm Vi Gaseous 1 Prjcj                      $110.39
78593         Pulm Vi Gaseous Rbrthing&Wshot 1 Prjcj       $158.99
78593   26    Pulm Vi Gaseous Rbrthing&Wshot 1 Prjcj        $25.03
78593   TC    Pulm Vi Gaseous Rbrthing&Wshot 1 Prjcj       $133.97
78594         Pulm Vi Gaseous Rbrthing&Wshot Mlt Prjcj     $219.56
78594   26    Pulm Vi Gaseous Rbrthing&Wshot Mlt Prjcj      $26.85
78594   TC    Pulm Vi Gaseous Rbrthing&Wshot Mlt Prjcj     $192.71
78596         Pulm Quan Diffial Funcj Vntj/Prfuj Std       $339.52
78596   26    Pulm Quan Diffial Funcj Vntj/Prfuj Std        $64.44
78596   TC    Pulm Quan Diffial Funcj Vntj/Prfuj Std       $275.08
78599         Unlis Respir Px Dx Nuc Med                     $0.00
78599   26    Unlis Respir Px Dx Nuc Med                     $0.00
78599   TC    Unlis Respir Px Dx Nuc Med                     $0.00
78600         Brn Img Lmtd Px Static                       $133.95
78600   26    Brn Img Lmtd Px Static                        $22.45
78600   TC    Brn Img Lmtd Px Static                       $111.50
78601         Brn Img Lmtd Px Vasc Flo                     $157.91
78601   26    Brn Img Lmtd Px Vasc Flo                      $25.77
78601   TC    Brn Img Lmtd Px Vasc Flo                     $132.14
78605         Brn Img Compl Std Static                     $159.39
78605   26    Brn Img Compl Std Static                      $27.24
78605   TC    Brn Img Compl Std Static                     $132.15
78606         Brn Img Compl Std Vasc Flo                   $183.79
78606   26    Brn Img Compl Std Vasc Flo                    $33.16
78606   TC    Brn Img Compl Std Vasc Flo                   $150.63
78607         Brn Img Compl Std Tomog Spect                $318.59
78607   26    Brn Img Compl Std Tomog Spect                 $63.34
78607   TC    Brn Img Compl Std Tomog Spect                $255.25
78608         Brn Img P+ Emij Tomog Metab Eval               $0.00
78608   26    Brn Img P+ Emij Tomog Metab Eval               $0.00
78608   TC    Brn Img P+ Emij Tomog Metab Eval               $0.00
78609         Brn Img P+ Emij Tomog Prfuj Eval               $0.00
78609   26    Brn Img P+ Emij Tomog Prfuj Eval               $0.00
78609   TC    Brn Img P+ Emij Tomog Prfuj Eval               $0.00
78610         Brn Img Vasc Flo Only                         $77.39
78610   26    Brn Img Vasc Flo Only                         $15.48
78610   TC    Brn Img Vasc Flo Only                         $61.91
78615         Cere Vasc Flo                                $171.84
78615   26    Cere Vasc Flo                                 $22.08
78615   TC    Cere Vasc Flo                                $149.76
78630         Cerebsp Flu Flo Img X Intro Matrl Cistrng    $230.81
78630   26    Cerebsp Flu Flo Img X Intro Matrl Cistrng     $34.97
78630   TC    Cerebsp Flu Flo Img X Intro Matrl Cistrng    $195.84
78635         Cerebsp Flu Flo Img X Intro Matrl Ventrg     $131.53
78635   26    Cerebsp Flu Flo Img X Intro Matrl Ventrg      $32.05
78635   TC    Cerebsp Flu Flo Img X Intro Matrl Ventrg      $99.48

                                            Page 162
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
78640         Cerebrospinal Fluid Flow, Imaging (Not Including Introductio   $145.60
78640   26    Cerebrospinal Fluid Flow, Imaging (Not Including Introductio    $43.68
78640   TC    Cerebrospinal Fluid Flow, Imaging (Not Including Introductio   $101.92
78645         Cerebsp Flu Flo Img X Intro Matrl Shunt Eval                   $162.34
78645   26    Cerebsp Flu Flo Img X Intro Matrl Shunt Eval                    $29.08
78645   TC    Cerebsp Flu Flo Img X Intro Matrl Shunt Eval                   $133.26
78647         Cerebsp Flu Flo Img X Intro Matrl Tomog Spect                  $276.07
78647   26    Cerebsp Flu Flo Img X Intro Matrl Tomog Spect                   $46.38
78647   TC    Cerebsp Flu Flo Img X Intro Matrl Tomog Spect                  $229.69
78650         Cerebsp Flu Leakage Detcj&Loclzj                               $211.19
78650   26    Cerebsp Flu Leakage Detcj&Loclzj                                $30.90
78650   TC    Cerebsp Flu Leakage Detcj&Loclzj                               $180.29
78652         Cerebrospinal Fluid Flow, Imaging (Not Including Introductio   $249.65
78652   26    Cerebrospinal Fluid Flow, Imaging (Not Including Introductio    $74.90
78652   TC    Cerebrospinal Fluid Flow, Imaging (Not Including Introductio   $174.76
78655         Radionuclide Identification Of Eye Tumor                       $209.81
78655   26    Radionuclide Identification Of Eye Tumor                        $62.94
78655   TC    Radionuclide Identification Of Eye Tumor                       $146.87
78660         Rp Dacryocstograpy                                             $109.47
78660   26    Rp Dacryocstograpy                                              $26.91
78660   TC    Rp Dacryocstograpy                                              $82.56
78699         Unlis Nrvs Sys Px Dx Nuc Med                                     $0.00
78699   26    Unlis Nrvs Sys Px Dx Nuc Med                                     $0.00
78699   TC    Unlis Nrvs Sys Px Dx Nuc Med                                     $0.00
78700         Kidney Imaging Morphology                                      $141.34
78700   26    Kidney Imaging Morphology                                       $22.83
78700   TC    Kidney Imaging Morphology                                      $118.51
78701         Kdn Img Vasc Flo                                               $163.00
78701   26    Kdn Img Vasc Flo                                                $25.02
78701   TC    Kdn Img Vasc Flo                                               $137.98
78704         Kidney Imaging; With Function Study (Ie, Imaging Renogram)     $191.90
78704   26    Kidney Imaging; With Function Study (Ie, Imaging Renogram)      $37.94
78704   TC    Kidney Imaging; With Function Study (Ie, Imaging Renogram)     $153.96
78707         Kidney Img Morphology Vascular Flow 1 W/O Rx                   $222.88
78707   26    Kidney Img Morphology Vascular Flow 1 W/O Rx                    $49.37
78707   TC    Kidney Img Morphology Vascular Flow 1 W/O Rx                   $173.51
78708         Kidney Img Morphology Vascular Flow 1 W Rx                     $235.54
78708   26    Kidney Img Morphology Vascular Flow 1 W Rx                      $61.92
78708   TC    Kidney Img Morphology Vascular Flow 1 W Rx                     $173.62
78709         Kidney Img Morphology Vascular Flow Multiple                   $245.61
78709   26    Kidney Img Morphology Vascular Flow Multiple                    $71.91
78709   TC    Kidney Img Morphology Vascular Flow Multiple                   $173.70
78710         Kidney Imaging Morphology Tomographic                          $263.46
78710   26    Kidney Imaging Morphology Tomographic                           $33.85
78710   TC    Kidney Imaging Morphology Tomographic                          $229.61
78715         Kidney Vascular Flow Only                                       $77.39
78715   26    Kidney Vascular Flow Only                                       $15.48
78715   TC    Kidney Vascular Flow Only                                       $61.91
78720         Kidney Function Study Only (Ie, Renogram)                       $72.80
78720   26    Kidney Function Study Only (Ie, Renogram)                       $21.84
78720   TC    Kidney Function Study Only (Ie, Renogram)                       $50.96
78725         Kdn Funcj Std Non-Img Radioisotopic Std                         $89.18
78725   26    Kdn Funcj Std Non-Img Radioisotopic Std                         $19.16
78725   TC    Kdn Funcj Std Non-Img Radioisotopic Std                         $70.02
78730         Urinary Bladder Residual Study                                  $75.57

                                             Page 163
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                    Amount
78730    26   Urinary Bladder Residual Study                  $18.80
78730   TC    Urinary Bladder Residual Study                  $56.77
78740         Urtrl Rflx Std Rp Voiding Cstogram             $111.33
78740   26    Urtrl Rflx Std Rp Voiding Cstogram              $28.76
78740   TC    Urtrl Rflx Std Rp Voiding Cstogram              $82.57
78760         Testicular Imaging;                            $137.86
78760   26    Testicular Imaging;                             $33.91
78760   TC    Testicular Imaging;                            $103.95
78761         Testicular Imaging With Vascular Flow          $161.04
78761   26    Testicular Imaging With Vascular Flow           $36.48
78761   TC    Testicular Imaging With Vascular Flow          $124.56
78770         Palcenta Imagng                                 $79.17
78770   26    Palcenta Imagng                                 $23.75
78770   TC    Palcenta Imagng                                 $55.42
78775         Nuclear Scan Of Placenta                        $65.52
78775   26    Nuclear Scan Of Placenta                        $19.66
78775   TC    Nuclear Scan Of Placenta                        $45.86
78799         Unlis Genitour Dx Nuc Med                        $0.00
78799   26    Unlis Genitour Dx Nuc Med                        $0.00
78799   TC    Unlis Genitour Dx Nuc Med                        $0.00
78800         Rp Loclzj Tum/Dstrbj Agt Lmtd Area             $166.15
78800   26    Rp Loclzj Tum/Dstrbj Agt Lmtd Area              $33.89
78800   TC    Rp Loclzj Tum/Dstrbj Agt Lmtd Area             $132.26
78801         Rp Loclzj Tum/Dstrbj Agt Mlt Areas             $204.77
78801   26    Rp Loclzj Tum/Dstrbj Agt Mlt Areas              $40.50
78801   TC    Rp Loclzj Tum/Dstrbj Agt Mlt Areas             $164.27
78802         Rp Loclzj Tum/Dstrbj Agt Whbdy 1 D Img         $259.57
78802   26    Rp Loclzj Tum/Dstrbj Agt Whbdy 1 D Img          $44.18
78802   TC    Rp Loclzj Tum/Dstrbj Agt Whbdy 1 D Img         $215.39
78803         Rp Loclzj Tum/Dstrbj Agt Tomog Spect           $311.13
78803   26    Rp Loclzj Tum/Dstrbj Agt Tomog Spect            $55.97
78803   TC    Rp Loclzj Tum/Dstrbj Agt Tomog Spect           $255.16
78804         Rp Loclzj Tum/Dstrbj Agt Whbdy Req 2/> D Img   $223.95
78804   26    Rp Loclzj Tum/Dstrbj Agt Whbdy Req 2/> D Img    $54.60
78804   TC    Rp Loclzj Tum/Dstrbj Agt Whbdy Req 2/> D Img   $169.35
78805         Rp Loclzj Inflammatory Process Lmtd Area       $169.86
78805   26    Rp Loclzj Inflammatory Process Lmtd Area        $37.59
78805   TC    Rp Loclzj Inflammatory Process Lmtd Area       $132.27
78806         Rp Loclzj Inflammatory Process Whbdy           $294.47
78806   26    Rp Loclzj Inflammatory Process Whbdy            $44.17
78806   TC    Rp Loclzj Inflammatory Process Whbdy           $250.30
78807         Rp Loclzj Inflammatory Process Tomog Spect     $311.49
78807   26    Rp Loclzj Inflammatory Process Tomog Spect      $56.35
78807   TC    Rp Loclzj Inflammatory Process Tomog Spect     $255.14
78810         Tumor Pet Metabolic Evaluation                   $0.00
78810   26    Tumor Pet Metabolic Evaluation                 $103.56
78810   TC    Tumor Pet Metabolic Evaluation                   $0.00
78890         Gnrj Auto Data Ia Pcx Smpl X Exceed 30 Min      $53.28
78890   26    Gnrj Auto Data Ia Pcx Smpl X Exceed 30 Min       $2.94
78890   TC    Gnrj Auto Data Ia Pcx Smpl X Exceed 30 Min      $50.34
78891         Gnrj Auto Data Ia Pcx Cplx Exceeding 30 Min    $106.56
78891   26    Gnrj Auto Data Ia Pcx Cplx Exceeding 30 Min      $5.51
78891   TC    Gnrj Auto Data Ia Pcx Cplx Exceeding 30 Min    $101.05
78895         Bedside Unit Required                           $45.50
78990         Supply Of Radiopharmaceutical(S)                $50.00

                                           Page 164
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
78999         Unlis Misc Dx Nuc Med                                            $0.00
78999   26    Unlis Misc Dx Nuc Med                                            $0.00
78999   TC    Unlis Misc Dx Nuc Med                                            $0.00
79000         Nuclear Therapy, Hyperthyroidism                               $193.74
79000   26    Nuclear Therapy, Hyperthyroidism                                $91.70
79000   TC    Nuclear Therapy, Hyperthyroidism                               $102.04
79001         Nuclear Therapy, Hyperthyroidism                               $105.07
79001   26    Nuclear Therapy, Hyperthyroidism                                $54.02
79001   TC    Nuclear Therapy, Hyperthyroidism                                $51.05
79005         Rp Ther Oral Admn                                              $197.33
79005   26    Rp Ther Oral Admn                                               $93.85
79005   TC    Rp Ther Oral Admn                                              $103.47
79020         Nuclear Therapy,Thyroid Suppression                            $194.12
79020   26    Nuclear Therapy,Thyroid Suppression                             $92.07
79020   TC    Nuclear Therapy,Thyroid Suppression                            $102.05
79030         Nuclear Therapy For Thyroid Tumor                              $209.77
79030   26    Nuclear Therapy For Thyroid Tumor                              $107.65
79030   TC    Nuclear Therapy For Thyroid Tumor                              $102.12
79035         Nuclear Therapy For Thyroid Tumor                              $232.07
79035   26    Nuclear Therapy For Thyroid Tumor                              $129.91
79035   TC    Nuclear Therapy For Thyroid Tumor                              $102.16
79100         Nuclear Tx Blood Defect, Ea By Iv                              $169.89
79100   26    Nuclear Tx Blood Defect, Ea By Iv                               $67.96
79100   TC    Nuclear Tx Blood Defect, Ea By Iv                              $101.93
79101         Rp Ther Iv Admn                                                $206.00
79101   26    Rp Ther Iv Admn                                                $102.53
79101   TC    Rp Ther Iv Admn                                                $103.47
79200         Rp Ther Intrcv Admn                                            $204.12
79200   26    Rp Ther Intrcv Admn                                            $102.06
79200   TC    Rp Ther Intrcv Admn                                            $102.06
79300         Rp Ther Ntrstl Radact Col Admn                                  $83.30
79300   26    Rp Ther Ntrstl Radact Col Admn                                  $83.44
79300   TC    Rp Ther Ntrstl Radact Col Admn                                   $0.00
79400         Nuclear Tx, Not Thyr/Blood, By Iv                              $203.09
79400   26    Nuclear Tx, Not Thyr/Blood, By Iv                              $101.00
79400   TC    Nuclear Tx, Not Thyr/Blood, By Iv                              $102.09
79403         Rp Ther Radiolbld Monoclonal Antb Iv Nfs                       $283.29
79403   26    Rp Ther Radiolbld Monoclonal Antb Iv Nfs                       $119.89
79403   TC    Rp Ther Radiolbld Monoclonal Antb Iv Nfs                       $163.40
79420         Intravascular Radiotherapy                                      $78.95
79420   26    Intravascular Radiotherapy                                      $77.12
79420   TC    Intravascular Radiotherapy                                       $0.00
79440         Rp Ther Intra-Articular Admn                                   $206.03
79440   26    Rp Ther Intra-Articular Admn                                   $103.94
79440   TC    Rp Ther Intra-Articular Admn                                   $102.09
79445         Rp Ther Ia Part Admn                                           $230.71
79445   26    Rp Ther Ia Part Admn                                           $126.43
79445   TC    Rp Ther Ia Part Admn                                           $104.28
79900         Supply Of Radiopharmaceutical(S)                                 $0.00
79999         Rp Ther Unlis Px                                                 $0.00
79999   26    Rp Ther Unlis Px                                                 $0.00
79999   TC    Rp Ther Unlis Px                                                 $0.00
80031         Therapeutic Quantitative Drug Monitoring In Body Fluids And/    $15.28
80031   26    Therapeutic Quantitative Drug Monitoring In Body Fluids And/     $4.58
80031   TC    Therapeutic Quantitative Drug Monitoring In Body Fluids And/    $10.70

                                             Page 165
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
80032         Therapeutic Quantitative Drug Monitoring In Body Fluids And/    $19.00
80032   26    Therapeutic Quantitative Drug Monitoring In Body Fluids And/     $5.70
80032   TC    Therapeutic Quantitative Drug Monitoring In Body Fluids And/    $13.30
80033         Therapeutic Quantitative Drug Monitoring In Body Fluids And/    $19.00
80033   26    Therapeutic Quantitative Drug Monitoring In Body Fluids And/     $5.70
80033   TC    Therapeutic Quantitative Drug Monitoring In Body Fluids And/    $13.30
80034         Therapeutic Quantitative Drug Monitoring In Body Fluids And/    $19.00
80034   26    Therapeutic Quantitative Drug Monitoring In Body Fluids And/     $5.70
80034   TC    Therapeutic Quantitative Drug Monitoring In Body Fluids And/    $13.30
80040         Serum Radioimmunoassay For Circulating Antibiotic Levels        $21.48
80040   26    Serum Radioimmunoassay For Circulating Antibiotic Levels         $6.44
80040   TC    Serum Radioimmunoassay For Circulating Antibiotic Levels        $15.04
80042         Serum Antimicrobial Level, Bioassay Method                      $24.28
80042   26    Serum Antimicrobial Level, Bioassay Method                       $7.28
80042   TC    Serum Antimicrobial Level, Bioassay Method                      $17.00
80048         Basic Metab Panel                                               $11.83
80049         Basic Metabolic Health Panel                                    $11.29
80050         General Hlth Panel                                              $48.08
80051         Electrolyte Panel                                                $9.80
80052         Pre-Marital Profile                                             $28.50
80052   26    Pre-Marital Profile                                              $8.55
80052   TC    Pre-Marital Profile                                             $19.95
80053         Compre Metab Panel                                              $14.77
80054         Comprehensive Metabolic Panel                                   $14.61
80055         Ob Panel                                                        $27.72
80056         Amenorrhea Profile                                              $42.98
80056   26    Amenorrhea Profile                                              $12.89
80056   TC    Amenorrhea Profile                                              $30.09
80057         Male Infertility And/Or Gynecomastia Profile                     $0.00
80057   26    Male Infertility And/Or Gynecomastia Profile                     $0.00
80057   TC    Male Infertility And/Or Gynecomastia Profile                     $0.00
80058         Hepatic Function Panel)                                         $11.29
80059         Hepatitis Panel                                                 $80.93
80060         Hypertension Panel                                              $42.50
80060   26    Hypertension Panel                                              $12.75
80060   TC    Hypertension Panel                                              $29.75
80061         Lipid Panel                                                     $18.72
80062         Cardiac Evaluation (Including Coronary Risk) Panel              $31.89
80062   26    Cardiac Evaluation (Including Coronary Risk) Panel               $9.57
80062   TC    Cardiac Evaluation (Including Coronary Risk) Panel              $22.32
80063         Cardiac Injury Panel;                                           $34.02
80063   26    Cardiac Injury Panel;                                           $10.21
80063   TC    Cardiac Injury Panel;                                           $23.81
80064         Cardiac Injury Panel; With Creatine Phosphokinase (Cpk) And/    $36.18
80064   26    Cardiac Injury Panel; With Creatine Phosphokinase (Cpk) And/    $10.85
80064   TC    Cardiac Injury Panel; With Creatine Phosphokinase (Cpk) And/    $25.33
80065         Metabolic Panel                                                 $23.40
80065   26    Metabolic Panel                                                  $7.02
80065   TC    Metabolic Panel                                                 $16.38
80066         Malabsorption Panel                                             $24.70
80066   26    Malabsorption Panel                                              $7.41
80066   TC    Malabsorption Panel                                             $17.29
80067         Pulmonary (Lung Function) Panel                                 $38.20
80067   26    Pulmonary (Lung Function) Panel                                 $11.46
80067   TC    Pulmonary (Lung Function) Panel                                 $26.74

                                            Page 166
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
80068         Lung Maturity Profile                                           $40.35
80068   26    Lung Maturity Profile                                           $12.11
80068   TC    Lung Maturity Profile                                           $28.25
80069         Rnl Funcj Panel                                                 $12.13
80070         Thyroid Panel;                                                  $20.89
80070   26    Thyroid Panel;                                                   $6.27
80070   TC    Thyroid Panel;                                                  $14.62
80071         Thyroid Panel; With Thyrotropin Releasing Hormone (Trh)         $20.89
80071   26    Thyroid Panel; With Thyrotropin Releasing Hormone (Trh)          $6.27
80071   TC    Thyroid Panel; With Thyrotropin Releasing Hormone (Trh)         $14.62
80072         Arthritis Panel                                                 $35.67
80073         Renal Panel                                                     $25.54
80073   26    Renal Panel                                                      $7.66
80073   TC    Renal Panel                                                     $17.88
80074         Aqt Hep Panel                                                   $64.83
80075         Parathyroid Panel                                               $14.92
80075   26    Parathyroid Panel                                                $4.48
80075   TC    Parathyroid Panel                                               $10.44
80076         Hepatc Funcj Panel                                              $11.42
80080         Prostatic Panel                                                 $21.26
80080   26    Prostatic Panel                                                  $6.38
80080   TC    Prostatic Panel                                                 $14.88
80082         Pancreatic Panel                                                $21.26
80082   26    Pancreatic Panel                                                 $6.38
80082   TC    Pancreatic Panel                                                $14.88
80084         Pituitary Panel                                                 $21.26
80084   26    Pituitary Panel                                                  $6.38
80084   TC    Pituitary Panel                                                 $14.88
80085         Microcytic Anemia Panel                                         $40.35
80085   26    Microcytic Anemia Panel                                         $12.11
80085   TC    Microcytic Anemia Panel                                         $28.25
80086         Macrocytic Anemia Panel                                         $40.35
80086   26    Macrocytic Anemia Panel                                         $12.11
80086   TC    Macrocytic Anemia Panel                                         $28.25
80088         Transition Panel (For Management Of Patient With Proven Meta    $42.50
80088   26    Transition Panel (For Management Of Patient With Proven Meta    $12.75
80088   TC    Transition Panel (For Management Of Patient With Proven Meta    $29.75
80089         Muscle Panel                                                    $40.35
80089   26    Muscle Panel                                                    $12.11
80089   TC    Muscle Panel                                                    $28.25
80090         Torch Antibody Panel                                            $79.56
80091         Thyroid Panel                                                   $18.45
80092         Thyroid Panel With Thyroid Stimulating Hormone                  $41.66
80099         Unlisted Panel                                                   $0.00
80099   26    Unlisted Panel                                                   $0.00
80099   TC    Unlisted Panel                                                   $0.00
80100         Drug Scr Qual Mlt Drug Classes Chrom Ea Px                      $20.32
80101         Drug Scr Qual 1 Drug Class Meth Ea Drug Class                   $17.14
80102         Drug Confirmation Ea Px                                         $17.68
80103         Tiss Prepj Drug Alys                                             $0.00
80150         Amikacin                                                        $18.46
80152         Amitriptyline                                                   $25.01
80154         Benzodiazepines                                                 $25.84
80156         Carbamazepine Tot                                               $20.34
80157         Carbamazepine Fr                                                $18.52

                                            Page 167
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                   Amount
80158         Cyclosporine                                   $25.23
80160         Desipramine                                    $24.05
80162         Digoxin                                        $18.55
80164         Dipropylacetic Acid                            $16.64
80166         Doxepin                                        $21.66
80168         Ethosuximide                                   $22.83
80170         Gentamicin                                     $22.90
80172         Gold                                           $22.76
80173         Halopridol                                     $20.34
80174         Imipramine                                     $23.92
80176         Lidocaine                                      $20.52
80178         Lithium                                         $9.24
80182         Nortriptyline                                  $16.64
80184         Phenobarbital                                  $16.01
80185         Phenytoin Tot                                  $18.52
80186         Phenytoin Fr                                   $19.23
80188         Primidone                                      $23.18
80190         Procainamide                                   $23.41
80192         Procainamide Metabolites                       $23.41
80194         Quinidine                                      $20.39
80195         Sirolimus                                      $19.17
80196         Salicylate                                      $9.92
80197         Tacrolimus                                     $19.17
80198         Theophylline                                   $19.77
80200         Tobramycin                                     $22.52
80201         Topiramate                                     $16.66
80202         Vancomycin                                     $16.64
80299         Quan Drug Nes                                  $17.54
80400         Acth Stimj Panel Adrnl Insufficiency           $45.56
80402         Acth Stimj Panel 21 Hydroxylase Defncy        $121.46
80406         Acth Stimj Panel 3 Beta-Hydroxydehyd Defncy   $109.34
80408         Aldosterone Suprj Eval Panel                  $175.34
80410         Calcitonin Stimj Panel                        $112.23
80412         Corticotropic Releasing Horm Stimj Panel      $460.50
80414         Chornc Gonad Stimj Panel Tstosterone Rspse     $72.16
80415         Chornc Gonad Stimj Panel Estradiol Rspse       $78.08
80416         Rnl Vein Renin Stimj Panel                    $184.38
80417         Prph Vein Renin Stimj Panel                    $61.46
80418         Cmbn Rapid Ant Pituitary Eval Panel           $809.76
80420         Dxmethasone Suprj Panel 48 Hr                 $100.64
80422         Gluc Tolerance Panel Insulinoma                $54.60
80424         Gluc Tolerance Panel Pheochromocytoma          $63.44
80426         Gonad Releasing Horm Stimj Panel              $207.40
80428         Growth Horm Stimj Panel                        $93.16
80430         Growth Horm Suprj Panel Gluc Admn             $109.60
80432         Insulin-Induced C-Peptide Suprj Panel         $180.67
80434         Insulin Tolerance Panel Acth Insufficiency    $141.30
80435         Insulin Tolerance Panel Growth Horm Defncy    $143.85
80436         Metyrapone Panel                              $127.36
80438         Trh Stimj Panel 1 Hr                           $70.41
80439         Trh Stimj Panel 2 Hr                           $93.88
80440         Trh Stimj Panel Hyprprolactinemia              $81.24
80500         Clin Path Consltj Limited                      $22.26
80502         Clin Path Consltj Compre                       $74.74
81000         Urnls Dip Stick/Tablet Rgnt Non-Auto Mic        $4.43

                                           Page 168
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
81001         Urnls Dip Stick/Tablet Rgnt Auto Mic                             $4.43
81002         Urnls Dip Stick/Tablet Rgnt Non-Auto W/O Mic                     $3.57
81003         Urnls Dip Stick/Tablet Rgnt Auto W/O Mic                         $3.14
81004         Urinalysis; Components, Single, Not Otherwise Listed, Specif     $3.80
81004   26    Urinalysis; Components, Single, Not Otherwise Listed, Specif     $1.14
81004   TC    Urinalysis; Components, Single, Not Otherwise Listed, Specif     $2.66
81005         Urnls Qual/Semiquan Xcpt Ias                                     $3.03
81006         Urnlysis; Urine Vol Measurement                                  $5.70
81006   26    Urnlysis; Urine Vol Measurement                                  $1.71
81006   TC    Urnlysis; Urine Vol Measurement                                  $3.99
81007         Urnls Bacteriuria Scr Xcpt Culture/Dipstick                      $1.35
81010         Urinalysis; Concentration And Dilution Test                      $5.39
81010   26    Urinalysis; Concentration And Dilution Test                      $1.62
81010   TC    Urinalysis; Concentration And Dilution Test                      $3.77
81011         Urinalysis; Water Deprivation Test                               $3.80
81011   26    Urinalysis; Water Deprivation Test                               $1.14
81011   TC    Urinalysis; Water Deprivation Test                               $2.66
81012         Urinalysis; Water Deprivation Test With Vasopressin Response     $5.74
81012   26    Urinalysis; Water Deprivation Test With Vasopressin Response     $1.72
81012   TC    Urinalysis; Water Deprivation Test With Vasopressin Response     $4.02
81015         Urnls Mcrscp Only                                                $4.24
81020         Urnls 2/3 Glass Tst                                              $5.15
81025         Urine Pregnancy Tst Vis Color Cmprsn Meths                       $8.84
81030         Quantitative Sediment Analysis And Quantitative Protein (Add    $10.78
81030   26    Quantitative Sediment Analysis And Quantitative Protein (Add     $3.23
81030   TC    Quantitative Sediment Analysis And Quantitative Protein (Add     $7.55
81050         Vol Meas Tmd Collj Ea                                            $4.19
81099         Unlis Urnls                                                      $0.00
82000         Acetaldehyde Bld                                                $17.31
82003         Acetaminophen                                                   $28.28
82005         Acetoacetic Acid                                                $15.34
82005   26    Acetoacetic Acid                                                 $4.60
82005   TC    Acetoacetic Acid                                                $10.74
82009         Acetone/Oth Ketone Bodies Serum Qual                             $6.31
82010         Acetone/Oth Ketone Bodies Serum Quan                            $11.42
82011         Acetylsalicylic Acid; Quantitative                              $10.82
82011   26    Acetylsalicylic Acid; Quantitative                               $3.25
82011   TC    Acetylsalicylic Acid; Quantitative                               $7.57
82012         Acetylsalicylic Acid; Qualitative                                $9.87
82012   26    Acetylsalicylic Acid; Qualitative                                $2.96
82012   TC    Acetylsalicylic Acid; Qualitative                                $6.91
82013         Acetylcholinesterase                                            $15.61
82015         Acidity, Titratable, Urine                                       $9.16
82015   26    Acidity, Titratable, Urine                                       $2.75
82015   TC    Acidity, Titratable, Urine                                       $6.41
82016         Acylcarnitines Qual Ea Spec                                     $19.37
82017         Acylcarnitines Quan Ea Spec                                     $23.57
82024         Adrenocorticotropic Horm                                        $53.97
82030         Adenosine 5-Monophosphate Cyclic                                $36.05
82035         Adenosine; 5'-Triphosphate, Blood                               $22.48
82035   26    Adenosine; 5'-Triphosphate, Blood                                $6.74
82035   TC    Adenosine; 5'-Triphosphate, Blood                               $15.74
82040         Albumin Serum                                                    $6.92
82042         Albumin Urine/Oth Src Quan Ea Spec                               $7.23
82043         Albumin Urine Microalbumin Quan                                  $8.09

                                            Page 169
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                              Amount
82044         Albumin Urine Microalbumin Semiquan                        $6.39
82055         Alcohol Any Spec Xcpt Brth                                $15.10
82060         Alcohol (Ethanol), Blood; By Gas-Liquid Chromatography    $15.34
82060   26    Alcohol (Ethanol), Blood; By Gas-Liquid Chromatography     $4.60
82060   TC    Alcohol (Ethanol), Blood; By Gas-Liquid Chromatography    $10.74
82065         Alcohol (Ethanol), Urine; Chemical                        $16.39
82065   26    Alcohol (Ethanol), Urine; Chemical                         $4.92
82065   TC    Alcohol (Ethanol), Urine; Chemical                        $11.47
82070         Alcohol (Ethanol), Urine; By Gas-Liquid Chromatography    $15.34
82070   26    Alcohol (Ethanol), Urine; By Gas-Liquid Chromatography     $4.60
82070   TC    Alcohol (Ethanol), Urine; By Gas-Liquid Chromatography    $10.74
82072         Alcohol (Ethanol) Gelation                                $13.92
82072   26    Alcohol (Ethanol) Gelation                                 $4.18
82072   TC    Alcohol (Ethanol) Gelation                                 $9.74
82075         Alcohol Brth                                              $16.84
82076         Alcohol; Isopropyl                                        $15.76
82076   26    Alcohol; Isopropyl                                         $4.73
82076   TC    Alcohol; Isopropyl                                        $11.03
82078         Alcohol; Methyl                                           $16.95
82078   26    Alcohol; Methyl                                            $5.09
82078   TC    Alcohol; Methyl                                           $11.87
82085         Aldolase                                                  $13.56
82086         Aldolase, Blood; Colorimetric                              $8.48
82086   26    Aldolase, Blood; Colorimetric                              $2.54
82086   TC    Aldolase, Blood; Colorimetric                              $5.94
82087         Aldosterone; Double Isotope Technique                     $63.98
82087   26    Aldosterone; Double Isotope Technique                     $19.19
82087   TC    Aldosterone; Double Isotope Technique                     $44.79
82088         Aldosterone                                               $56.94
82089         Aldosterone; Ria, Urine                                   $60.91
82089   26    Aldosterone; Ria, Urine                                   $18.27
82089   TC    Aldosterone; Ria, Urine                                   $42.64
82091         Aldosterone; Saline Infusion Test                         $60.99
82091   26    Aldosterone; Saline Infusion Test                         $18.30
82091   TC    Aldosterone; Saline Infusion Test                         $42.69
82095         Alkaloids, Tissue; Screening                              $26.22
82095   26    Alkaloids, Tissue; Screening                               $7.87
82095   TC    Alkaloids, Tissue; Screening                              $18.35
82096         Alkaloids, Tissue; Quantitative                           $45.75
82096   26    Alkaloids, Tissue; Quantitative                           $13.73
82096   TC    Alkaloids, Tissue; Quantitative                           $32.03
82100         Alkaloids, Urine; Screening                               $19.78
82100   26    Alkaloids, Urine; Screening                                $5.93
82100   TC    Alkaloids, Urine; Screening                               $13.85
82101         Alkaloids Urine Quan                                      $41.94
82103         Alpha-1-Antitrypsin Tot                                   $18.77
82104         Alpha-1-Antitrypsin Phexyp                                $20.20
82105         Alpha-Fetoprotein Serum                                   $18.46
82106         Alpha-Fetoprotein Amniotic Flu                            $18.46
82108         Aluminum                                                  $35.60
82112         Amikacin                                                  $16.95
82112   26    Amikacin                                                   $5.09
82112   TC    Amikacin                                                  $11.87
82120         Amines Vag Flu Qual                                        $5.25
82126         Amino Acid Nitrogen, Alpha                                $19.18

                                            Page 170
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                   Amount
82126    26   Amino Acid Nitrogen, Alpha                                      $5.75
82126   TC    Amino Acid Nitrogen, Alpha                                     $13.43
82127         Amino Acids 1 Qual Ea Spec                                     $19.37
82128         Amino Acids Mlt Qual Ea Spec                                   $19.37
82130         Amino Acids, Urine Or Plasma, Chromatographic Fractionation    $37.53
82131         Amino Acids 1 Quan Ea Spec                                     $23.57
82134         Aminohippurate, Para (Pah)                                     $12.77
82134   26    Aminohippurate, Para (Pah)                                      $3.83
82134   TC    Aminohippurate, Para (Pah)                                      $8.94
82135         Aminolevulinic Acid Delta                                      $23.00
82136         Amino Acids 2-5 Amino Acids Quan Ea Spec                       $23.57
82137         Aminophylline                                                  $20.98
82137   26    Aminophylline                                                   $6.29
82137   TC    Aminophylline                                                  $14.69
82138         Amitriptyline                                                  $26.89
82138   26    Amitriptyline                                                   $8.07
82138   TC    Amitriptyline                                                  $18.82
82139         Amino Acids 6/> Amino Acids Quan Ea Spec                       $23.57
82140         Ammonia                                                        $20.36
82141         Ammonia; Urine                                                 $12.77
82141   26    Ammonia; Urine                                                  $3.83
82141   TC    Ammonia; Urine                                                  $8.94
82142         Ammonium Chloride Loading Test                                 $16.95
82142   26    Ammonium Chloride Loading Test                                  $5.09
82142   TC    Ammonium Chloride Loading Test                                 $11.87
82143         Amniotic Flu Scan                                               $9.44
82145         Amphetamine/Methamphetamine                                    $21.72
82150         Amylase                                                         $9.06
82154         Androstanediol Glucuronide                                     $40.29
82155         Amylase, Serum;                                                $23.75
82155   26    Amylase, Serum;                                                 $7.13
82155   TC    Amylase, Serum;                                                $16.63
82156         Amylase, Urine (Diastase)                                       $9.87
82156   26    Amylase, Urine (Diastase)                                       $2.96
82156   TC    Amylase, Urine (Diastase)                                       $6.91
82157         Androstenedione                                                $40.90
82159         Androsterone;                                                  $34.02
82159   26    Androsterone;                                                  $10.21
82159   TC    Androsterone;                                                  $23.81
82160         Androsterone                                                   $34.94
82163         Angiotensin Ii                                                 $28.68
82164         Angiotensin I-Converting Enzyme                                $20.39
82165         Aniline                                                        $10.82
82165   26    Aniline                                                         $3.25
82165   TC    Aniline                                                         $7.57
82168         Antihistamines                                                 $19.13
82168   26    Antihistamines                                                  $5.74
82168   TC    Antihistamines                                                 $13.39
82170         Antimony, Urine                                                $38.88
82170   26    Antimony, Urine                                                $11.66
82170   TC    Antimony, Urine                                                $27.22
82172         Apolipoprotein Ea                                              $21.65
82173         Arginine Tolerance Test                                        $20.39
82173   26    Arginine Tolerance Test                                         $6.12
82173   TC    Arginine Tolerance Test                                        $14.27

                                            Page 171
                           MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
82175         Arsenic                                                         $26.51
82180         Ascorbic Acid Bld                                                $8.06
82190         Atomic Absrpj Spectroscopy Ea Anal                              $20.83
82205         Barbiturates Nes                                                $16.01
82210         Barbiturates; Quantitative And Identification                   $22.68
82210   26    Barbiturates; Quantitative And Identification                    $6.80
82210   TC    Barbiturates; Quantitative And Identification                   $15.88
82225         Barium                                                          $14.92
82225   26    Barium                                                           $4.48
82225   TC    Barium                                                          $10.44
82230         Beryllium, Urine                                                $32.77
82230   26    Beryllium, Urine                                                 $9.83
82230   TC    Beryllium, Urine                                                $22.94
82231         Beta-2 Microglobulin, Ria; Urine                                $24.68
82231   26    Beta-2 Microglobulin, Ria; Urine                                 $7.40
82231   TC    Beta-2 Microglobulin, Ria; Urine                                $17.28
82232         Beta-2 Microglobulin                                            $22.61
82235         Bicarbonate Excretion, Urine                                     $7.56
82235   26    Bicarbonate Excretion, Urine                                     $2.27
82235   TC    Bicarbonate Excretion, Urine                                     $5.29
82236         Bicarbonate Loading Test                                         $9.03
82236   26    Bicarbonate Loading Test                                         $2.71
82236   TC    Bicarbonate Loading Test                                         $6.32
82239         Bile Acids Tot                                                  $23.94
82240         Bile Acids Cholylglycine                                        $37.13
82245         Bile Pigments, Urine                                             $3.43
82245   26    Bile Pigments, Urine                                             $1.03
82245   TC    Bile Pigments, Urine                                             $2.40
82247         Bilirubin Tot                                                    $7.02
82248         Bilirubin Dir                                                    $7.02
82250         Bilirubin; Total Or Direct                                       $6.94
82251         Bili; Tot & Direct                                               $7.33
82252         Bilirubin Feces Qual                                             $6.35
82260         Bilirubin; Urine, Quantitative                                   $5.68
82260   26    Bilirubin; Urine, Quantitative                                   $1.70
82260   TC    Bilirubin; Urine, Quantitative                                   $3.98
82261         Biotinidase Ea Spec                                             $23.57
82265         Bilirubin; Amniotic Fluid, Quantitative                          $8.48
82265   26    Bilirubin; Amniotic Fluid, Quantitative                          $2.54
82265   TC    Bilirubin; Amniotic Fluid, Quantitative                          $5.94
82268         Bismuth                                                         $29.85
82268   26    Bismuth                                                          $8.96
82268   TC    Bismuth                                                         $20.90
82270         Bld Oclt Proxidase Actv Qual Feces 1 Deter                       $4.54
82271         Bld Oclt Proxidase Actv Qual Oth Srcs                            $4.54
82272         Bld Oclt Proxidase Actv Qual Feces 1 Spec                        $4.54
82273         Blood, Occult, By Peroxidase Activity (Eg, Guaiac), Qualitat     $4.54
82274         Bld Oclt Fecal Hgb Deter Ia Qual Feces 1-3                      $18.09
82280         Boric Acid; Blood                                               $36.76
82280   26    Boric Acid; Blood                                               $11.03
82280   TC    Boric Acid; Blood                                               $25.73
82285         Boric Acid; Urine                                               $33.83
82285   26    Boric Acid; Urine                                               $10.15
82285   TC    Boric Acid; Urine                                               $23.68
82286         Bradykinin                                                       $9.62

                                              Page 172
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                          Amount
82290         Bromides; Blood                                        $8.48
82290   26    Bromides; Blood                                        $2.54
82290   TC    Bromides; Blood                                        $5.94
82291         Bromides; Urine                                       $11.33
82291   26    Bromides; Urine                                        $3.40
82291   TC    Bromides; Urine                                        $7.93
82300         Cadmium                                               $32.33
82305         Caffeine                                              $29.95
82305   26    Caffeine                                               $8.99
82305   TC    Caffeine                                              $20.97
82306         Calcifediol 25-Oh Vit D-3                             $32.35
82307         Calciferol                                            $45.02
82308         Calcitonin                                            $37.41
82310         Calcium Tot                                            $7.20
82315         Calcium, Blood; Fluorometric                           $7.89
82315   26    Calcium, Blood; Fluorometric                           $2.37
82315   TC    Calcium, Blood; Fluorometric                           $5.52
82320         Calcium, Blood; Emission Flame Photometry              $7.89
82320   26    Calcium, Blood; Emission Flame Photometry              $2.37
82320   TC    Calcium, Blood; Emission Flame Photometry              $5.52
82325         Calcium, Blood; Atomic Absorption Flame Photometry     $7.94
82325   26    Calcium, Blood; Atomic Absorption Flame Photometry     $2.38
82325   TC    Calcium, Blood; Atomic Absorption Flame Photometry     $5.56
82330         Calcium Ionized                                       $18.72
82331         Calcium After Calcium Nfs Tst                          $7.23
82335         Calcium, Urine; Qualitative (Sulkowitch)               $7.25
82335   26    Calcium, Urine; Qualitative (Sulkowitch)               $2.18
82335   TC    Calcium, Urine; Qualitative (Sulkowitch)               $5.08
82340         Calcium Urine Quan Tmd Spec                            $8.43
82345         Calcium, Feces, Quantitative, Timed Specimen          $14.25
82345   26    Calcium, Feces, Quantitative, Timed Specimen           $4.28
82345   TC    Calcium, Feces, Quantitative, Timed Specimen           $9.98
82355         St1 Qual Alys                                         $16.17
82360         St1 Quan Alys Chem                                    $17.03
82365         St1 Infrared Spectroscopy                             $18.01
82370         St1 X-Ray Diffxj                                      $17.51
82372         Carbamazepine, Serum                                  $22.16
82372   26    Carbamazepine, Serum                                   $6.65
82372   TC    Carbamazepine, Serum                                  $15.51
82373         Carbohydrate Deficient Trrin                          $25.23
82374         Carbon Dioxide                                         $6.83
82375         Carbon Monoxide Carboxyhgb Quan                        $7.28
82376         Carbon Monoxide Carboxyhgb Qual                        $7.28
82378         Carcinoembryonic Ag                                   $26.51
82379         Carnitine Quan Ea Spec                                $23.57
82380         Carotene                                              $12.89
82382         Catecholamines Tot Urine                              $24.02
82383         Catecholamines Bld                                    $35.01
82384         Catecholamines Fxjated                                $31.72
82387         Cathepsin-D                                           $29.07
82390         Ceruloplasmin                                         $15.01
82397         Chemiluminescent Assay                                $19.74
82400         Chloral Hydrate; Blood                                $25.85
82400   26    Chloral Hydrate; Blood                                 $7.76
82400   TC    Chloral Hydrate; Blood                                $18.10

                                           Page 173
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                  Amount
82405         Chloral Hydrate; Urine                        $17.58
82405   26    Chloral Hydrate; Urine                         $5.27
82405   TC    Chloral Hydrate; Urine                        $12.31
82415         Chloramphenicol                               $17.70
82418         Chlorazepate Dipotassium                      $25.55
82418   26    Chlorazepate Dipotassium                       $7.67
82418   TC    Chlorazepate Dipotassium                      $17.89
82420         Chlordiazepoxide; Blood                       $27.32
82420   26    Chlordiazepoxide; Blood                        $8.20
82420   TC    Chlordiazepoxide; Blood                       $19.12
82425         Chlordiazepoxide; Urine                       $22.48
82425   26    Chlordiazepoxide; Urine                        $6.74
82425   TC    Chlordiazepoxide; Urine                       $15.74
82435         Chloride Bld                                   $6.42
82436         Chloride Urine                                 $7.02
82437         Chlorides; Sweat (Without Iontophoresis)      $10.38
82437   26    Chlorides; Sweat (Without Iontophoresis)       $3.11
82437   TC    Chlorides; Sweat (Without Iontophoresis)       $7.27
82438         Chloride Oth Src                               $6.83
82441         Chlorinated Hydrocarbons Scr                   $8.33
82443         Chlorothiazide-Hydrochlorothiazide            $26.89
82443   26    Chlorothiazide-Hydrochlorothiazide             $8.07
82443   TC    Chlorothiazide-Hydrochlorothiazide            $18.82
82465         Cholesterol Serum/Whl Bld Tot                  $6.08
82470         Cholesterol, Serum; Total And Esters          $10.62
82470   26    Cholesterol, Serum; Total And Esters           $3.19
82470   TC    Cholesterol, Serum; Total And Esters           $7.43
82480         Cholinesterase Serum                          $11.01
82482         Cholinesterase Rbc                            $10.74
82484         Cholinesterase; Serum And Rbc                 $22.19
82484   26    Cholinesterase; Serum And Rbc                  $6.66
82484   TC    Cholinesterase; Serum And Rbc                 $15.53
82485         Chondroitin B Sulfate Quan                    $28.85
82486         Chrom Qual Column Anal Nes                    $25.23
82487         Chrom Qual Papr 1-Dimensional Anal Nes        $22.30
82488         Chrom Qual Papr 2-Dimensional Anal Nes        $29.85
82489         Chrom Qual Thin Lyr Anal Nes                  $25.84
82490         Chromium;                                     $47.50
82490   26    Chromium;                                     $14.25
82490   TC    Chromium;                                     $33.25
82491         Chrom Quan Column 1 Anal Nes                  $25.23
82492         Chrom Quan Column Mlt Anals                   $25.23
82495         Chromium                                      $28.34
82505         Chymotrypsin, Duodenal Contents               $12.35
82505   26    Chymotrypsin, Duodenal Contents                $3.71
82505   TC    Chymotrypsin, Duodenal Contents                $8.65
82507         Citrate                                       $38.85
82512         Clonazepam                                    $29.11
82512   26    Clonazepam                                     $8.73
82512   TC    Clonazepam                                    $20.38
82520         Cocaine/Metabolite                            $21.17
82523         Collagen Cross Links Any Meth                 $26.11
82525         Coppr                                         $17.34
82526         Copper; Urine                                 $20.27
82526   26    Copper; Urine                                  $6.08

                                            Page 174
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
82526   TC    Copper; Urine                                                   $14.19
82528         Corticosterone                                                  $24.31
82529         Cortisol; Fluorometric, Plasma                                  $23.61
82529   26    Cortisol; Fluorometric, Plasma                                   $7.08
82529   TC    Cortisol; Fluorometric, Plasma                                  $16.53
82530         Cortisol Fr                                                     $23.35
82531         Cortisol; Cpb, Plasma                                           $26.01
82531   26    Cortisol; Cpb, Plasma                                            $7.80
82531   TC    Cortisol; Cpb, Plasma                                           $18.21
82532         Cortisol; Cpb, Urine                                            $29.41
82532   26    Cortisol; Cpb, Urine                                             $8.82
82532   TC    Cortisol; Cpb, Urine                                            $20.59
82533         Cortisol Tot                                                    $22.78
82534         Cortisol; Ria, Urine                                            $28.55
82534   26    Cortisol; Ria, Urine                                             $8.57
82534   TC    Cortisol; Ria, Urine                                            $19.99
82536         Cortisol; After Adrenocorticotropic Hormone (Acth) Administr    $26.27
82536   26    Cortisol; After Adrenocorticotropic Hormone (Acth) Administr     $7.88
82536   TC    Cortisol; After Adrenocorticotropic Hormone (Acth) Administr    $18.39
82537         Cortisol; 48 Hours After Continuous Acth Infusion               $26.27
82537   26    Cortisol; 48 Hours After Continuous Acth Infusion                $7.88
82537   TC    Cortisol; 48 Hours After Continuous Acth Infusion               $18.39
82538         Cortisol; After Metyrapone Tartrate Administration              $26.27
82538   26    Cortisol; After Metyrapone Tartrate Administration               $7.88
82538   TC    Cortisol; After Metyrapone Tartrate Administration              $18.39
82539         Cortisol; Dexamethasone Suppression Test, Plasma And/Or Urin    $25.21
82539   26    Cortisol; Dexamethasone Suppression Test, Plasma And/Or Urin     $7.56
82539   TC    Cortisol; Dexamethasone Suppression Test, Plasma And/Or Urin    $17.65
82540         Creatine                                                         $6.48
82541         Col-Chr/Ms Qual 1 Stationary&Mobile Phase                       $25.23
82542         Col-Chr/Ms Quan 1 Stationary&Mobile Phase                       $25.23
82543         Col-Chr/Ms Stable Isotope Dil 1 Anal                            $25.23
82544         Col-Chr/Ms Stable Isotope Dil Mlt Anals                         $25.23
82545         Creatine; Urine                                                  $7.99
82545   26    Creatine; Urine                                                  $2.40
82545   TC    Creatine; Urine                                                  $5.59
82546         Creatine And Creatinine                                         $11.42
82546   26    Creatine And Creatinine                                          $3.43
82546   TC    Creatine And Creatinine                                          $7.99
82550         Creatine Kinase Tot                                              $9.10
82552         Creatine Kinase Isoenzymes                                      $15.86
82553         Creatine Kinase Mb Fxj Only                                     $16.13
82554         Creatine Kinase Isoforms                                        $16.58
82555         Creatine Phosphokinase (Cpk), Blood; Colorimetric                $8.48
82555   26    Creatine Phosphokinase (Cpk), Blood; Colorimetric                $2.54
82555   TC    Creatine Phosphokinase (Cpk), Blood; Colorimetric                $5.94
82565         Creatinine Bld                                                   $7.16
82570         Creatinine Oth Src                                               $7.23
82575         Creatinine Clearance                                            $13.20
82585         Cryofibrn                                                       $11.98
82595         Cryoglobulin Qual/Semi-Quan                                      $6.50
82600         Cyanide                                                         $27.11
82601         Cyanide; Tissue                                                 $29.73
82601   26    Cyanide; Tissue                                                  $8.92
82601   TC    Cyanide; Tissue                                                 $20.81

                                           Page 175
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                           Amount
82606         Cyanocobalamin (Vitamin B-12); Bioassay                $21.85
82606   26    Cyanocobalamin (Vitamin B-12); Bioassay                 $6.56
82606   TC    Cyanocobalamin (Vitamin B-12); Bioassay                $15.30
82607         Cyanocobalamin                                         $21.06
82608         Cyanocobalamin Unsat Bndng Cap                         $20.01
82614         Cystine, Blood, Qualitative                            $13.12
82614   26    Cystine, Blood, Qualitative                             $3.94
82614   TC    Cystine, Blood, Qualitative                             $9.18
82615         Cstine&Homocstine Urine Qual                           $11.41
82620         Cystine And Homocystine, Urine; Quantitative           $18.08
82620   26    Cystine And Homocystine, Urine; Quantitative            $5.42
82620   TC    Cystine And Homocystine, Urine; Quantitative           $12.66
82624         Cystine Aminopeptidase                                 $15.61
82624   26    Cystine Aminopeptidase                                  $4.68
82624   TC    Cystine Aminopeptidase                                 $10.93
82626         Dehydroepiandrosterone                                 $35.31
82627         Dehydroepiandrosterone-Sulfate                         $31.07
82628         Desipramine                                            $26.27
82628   26    Desipramine                                             $7.88
82628   TC    Desipramine                                            $18.39
82633         Desoxycorticosterone 11-                               $37.04
82634         Deoxycortisol 11-                                      $40.90
82635         Diacetic Acid                                           $9.79
82635   26    Diacetic Acid                                           $2.94
82635   TC    Diacetic Acid                                           $6.85
82636         Diazepam                                               $19.46
82636   26    Diazepam                                                $5.84
82636   TC    Diazepam                                               $13.62
82638         Dibucaine Number                                       $17.11
82639         Dicumarol                                              $25.52
82639   26    Dicumarol                                               $7.66
82639   TC    Dicumarol                                              $17.86
82640         Digitoxin (Digitalis); Blood, Ria                      $21.53
82640   26    Digitoxin (Digitalis); Blood, Ria                       $6.46
82640   TC    Digitoxin (Digitalis); Blood, Ria                      $15.07
82641         Digitoxin (Digitalis); Urine                           $13.85
82641   26    Digitoxin (Digitalis); Urine                            $4.16
82641   TC    Digitoxin (Digitalis); Urine                            $9.70
82643         Digoxin, Ria                                           $20.18
82643   26    Digoxin, Ria                                            $6.05
82643   TC    Digoxin, Ria                                           $14.13
82646         Dihydrocodeinone                                       $28.85
82649         Dihydromorphinone                                      $35.91
82651         Dihydrotstosterone                                     $36.07
82652         Dihydroxyvit D 125-                                    $53.78
82654         Dimethadione                                           $19.34
82656         Elastase Pncrtc Fecal Qual/Semi-Quan                   $23.64
82656   26    Elastase Pncrtc Fecal Qual/Semi-Quan                    $7.09
82656   TC    Elastase Pncrtc Fecal Qual/Semi-Quan                   $16.55
82657         Nzm Actv Cells/Tiss Nonradact Substrate Ea             $25.23
82658         Nzm Actv Cells/Tiss Radact Substrate Ea                $25.23
82660         Drug Screen (Amphetamines, Barbiturates, Alkaloids)     $9.79
82660   26    Drug Screen (Amphetamines, Barbiturates, Alkaloids)     $2.94
82660   TC    Drug Screen (Amphetamines, Barbiturates, Alkaloids)     $6.85
82662         Immunoassay Technique For Drugs                         $0.00

                                            Page 176
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                       Amount
82664         Electrop Tq Nes                                    $48.00
82666         Epiandrosterone                                    $30.01
82668         Erythropoietin                                     $26.26
82670         Estradiol                                          $39.04
82671         Strgns Fxjated                                     $45.13
82672         Strgns Tot                                         $30.30
82673         Estriol; Fluorometric                              $20.18
82673   26    Estriol; Fluorometric                               $6.05
82673   TC    Estriol; Fluorometric                              $14.13
82674         Estriol; Glc                                       $20.18
82674   26    Estriol; Glc                                        $6.05
82674   TC    Estriol; Glc                                       $14.13
82676         Estriol; Chemical                                  $29.85
82676   26    Estriol; Chemical                                   $8.96
82676   TC    Estriol; Chemical                                  $20.90
82677         Estriol                                            $33.79
82678         Estrone; Chemical                                  $33.61
82678   26    Estrone; Chemical                                  $10.08
82678   TC    Estrone; Chemical                                  $23.53
82679         Estrone                                            $34.88
82690         Ethchlorvynol                                      $24.15
82691         Ethchlorvynol; Urine                               $23.21
82691   26    Ethchlorvynol; Urine                                $6.96
82691   TC    Ethchlorvynol; Urine                               $16.25
82692         Ethosuximide                                       $24.92
82692   26    Ethosuximide                                        $7.48
82692   TC    Ethosuximide                                       $17.44
82693         Ethylene Glycol                                    $20.82
82694         Etiocholanolone                                    $34.10
82694   26    Etiocholanolone                                    $10.23
82694   TC    Etiocholanolone                                    $23.87
82696         Etiocholanolone                                    $32.95
82705         Fat/Lipids Feces Qual                               $7.11
82710         Fat/Lipids Feces Quan                              $23.47
82715         Fat Diffial Feces Quan                             $24.05
82720         Fatty Acids, Blood; Esterified                     $16.39
82720   26    Fatty Acids, Blood; Esterified                      $4.92
82720   TC    Fatty Acids, Blood; Esterified                     $11.47
82725         Fatty Acids Nonesterified                           $8.97
82726         Very Long Chain Fatty Acids                        $25.23
82727         Ferric Chloride, Urine                             $14.92
82727   26    Ferric Chloride, Urine                              $4.48
82727   TC    Ferric Chloride, Urine                             $10.44
82728         Ferritin                                           $19.03
82730         Fibrinogen, Quantitative                           $13.14
82730   26    Fibrinogen, Quantitative                            $3.94
82730   TC    Fibrinogen, Quantitative                            $9.20
82731         Ftl Fibronectin Cervicovag Secretions Semi-Quan    $41.13
82735         Fluoride                                           $25.91
82740         Fluoride; Urine                                    $29.52
82740   26    Fluoride; Urine                                     $8.86
82740   TC    Fluoride; Urine                                    $20.66
82741         Flucytosine (5-Fluorocytosine)                     $22.59
82741   26    Flucytosine (5-Fluorocytosine)                      $6.78
82741   TC    Flucytosine (5-Fluorocytosine)                     $15.81

                                            Page 177
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                 Amount
82742         Flurazepam                                                   $27.66
82745         Folic Acid (Folate), Blood; Bioassay                         $22.19
82745   26    Folic Acid (Folate), Blood; Bioassay                          $6.66
82745   TC    Folic Acid (Folate), Blood; Bioassay                         $15.53
82746         Folic Acid Serum                                             $20.54
82747         Folic Acid Rbc                                               $24.20
82750         Formiminoglutamic Acid (Figlu), Urine                        $39.40
82750   26    Formiminoglutamic Acid (Figlu), Urine                        $11.82
82750   TC    Formiminoglutamic Acid (Figlu), Urine                        $27.58
82755         Free Radical Assay Technique For Drugs (Frat)                $20.89
82755   26    Free Radical Assay Technique For Drugs (Frat)                 $6.27
82755   TC    Free Radical Assay Technique For Drugs (Frat)                $14.62
82756         Free Thyroxine Index (T-7)                                   $16.39
82756   26    Free Thyroxine Index (T-7)                                    $4.92
82756   TC    Free Thyroxine Index (T-7)                                   $11.47
82757         Fructose Semen                                               $24.24
82759         Galactokinase Rbc                                            $30.01
82760         Galactose                                                    $15.64
82763         Galactose; Tolerance Test                                    $32.81
82763   26    Galactose; Tolerance Test                                     $9.84
82763   TC    Galactose; Tolerance Test                                    $22.97
82765         Galactose; Urine                                             $16.95
82765   26    Galactose; Urine                                              $5.09
82765   TC    Galactose; Urine                                             $11.87
82775         Galactose-1-Phosphate Uridyl Trase Quan                      $29.43
82776         Galactose-1-Phosphate Uridyl Trase Scr                       $11.71
82780         Gallium                                                      $36.14
82780   26    Gallium                                                      $10.84
82780   TC    Gallium                                                      $25.30
82784         Gg Iga Igd Igg Igm Ea                                         $7.40
82785         Gg Ige                                                       $23.01
82786         Gammaglobulin, Salt Precipitation Method                     $12.97
82786   26    Gammaglobulin, Salt Precipitation Method                      $3.89
82786   TC    Gammaglobulin, Salt Precipitation Method                      $9.08
82787         Gg Ig Subclasses Ea                                          $11.20
82790         Gases, Blood, Oxygen Saturation; By Calculation From Po2      $3.46
82790   26    Gases, Blood, Oxygen Saturation; By Calculation From Po2      $1.04
82790   TC    Gases, Blood, Oxygen Saturation; By Calculation From Po2      $2.42
82791         Gases, Blood, Oxygen Saturation; By Manometry                $16.80
82791   26    Gases, Blood, Oxygen Saturation; By Manometry                 $5.04
82791   TC    Gases, Blood, Oxygen Saturation; By Manometry                $11.76
82792         Gases, Blood, Oxygen Saturation Quantification               $13.14
82792   26    Gases, Blood, Oxygen Saturation Quantification                $3.94
82792   TC    Gases, Blood, Oxygen Saturation Quantification                $9.20
82793         Gases, Blood, Oxygen Saturation; By Spectrophotometry        $15.49
82793   26    Gases, Blood, Oxygen Saturation; By Spectrophotometry         $4.65
82793   TC    Gases, Blood, Oxygen Saturation; By Spectrophotometry        $10.84
82795         Gases, Blood, Oxygen Saturation; By Calculation From Pco2     $3.46
82795   26    Gases, Blood, Oxygen Saturation; By Calculation From Pco2     $1.04
82795   TC    Gases, Blood, Oxygen Saturation; By Calculation From Pco2     $2.42
82800         Gases Bld Ph Only                                            $11.83
82801         Gases, Blood; Pco2                                            $9.31
82801   26    Gases, Blood; Pco2                                            $2.79
82801   TC    Gases, Blood; Pco2                                            $6.52
82802         Gases, Blood; Ph, Pco2 By Electrode                          $19.23

                                            Page 178
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                              Amount
82802    26   Gases, Blood; Ph, Pco2 By Electrode                        $5.77
82802   TC    Gases, Blood; Ph, Pco2 By Electrode                       $13.46
82803         Gases Bld Ph Calculated O2 Saturation                     $24.31
82804         Gases, Blood; Po2 By Electrode                            $13.49
82804   26    Gases, Blood; Po2 By Electrode                             $4.05
82804   TC    Gases, Blood; Po2 By Electrode                             $9.44
82805         Gases Bld Ph Dir Meas Xcpt Pls Oximtry                    $38.55
82810         Gases Bld O2 Saturation Only Dir Meas                     $12.20
82812         Gases, Blood; Po2 By Manometry                            $13.57
82812   26    Gases, Blood; Po2 By Manometry                             $4.07
82812   TC    Gases, Blood; Po2 By Manometry                             $9.50
82817         Gases, Blood; Ph, Pco2 By Tonometry                       $13.61
82817   26    Gases, Blood; Ph, Pco2 By Tonometry                        $4.08
82817   TC    Gases, Blood; Ph, Pco2 By Tonometry                        $9.53
82820         Hgb-O2 Affinity Po2 50% Saturation Oxygen                 $13.25
82926         Gstr Acid Fr&Tot Ea Spec                                   $7.61
82927         Gastric Acid, Free And Total; Each Additional Specimen     $6.75
82927   26    Gastric Acid, Free And Total; Each Additional Specimen     $2.03
82927   TC    Gastric Acid, Free And Total; Each Additional Specimen     $4.73
82928         Gstr Acid Fr/Tot Ea Spec                                   $9.15
82929         Gastric Acid, Free Or Total; Each Additional Specimen      $5.43
82929   26    Gastric Acid, Free Or Total; Each Additional Specimen      $1.63
82929   TC    Gastric Acid, Free Or Total; Each Additional Specimen      $3.80
82931         Gastric Acid, Ph Titration; Single Specimen               $12.71
82931   26    Gastric Acid, Ph Titration; Single Specimen                $3.81
82931   TC    Gastric Acid, Ph Titration; Single Specimen                $8.90
82932         Gastric Acid, Ph Titration; Each Additional Specimen       $9.24
82932   26    Gastric Acid, Ph Titration; Each Additional Specimen       $2.77
82932   TC    Gastric Acid, Ph Titration; Each Additional Specimen       $6.47
82938         Gastrin After Secretin Stimj                              $24.72
82941         Gastrin                                                   $24.64
82942         Globulin, Serum                                            $6.57
82942   26    Globulin, Serum                                            $1.97
82942   TC    Globulin, Serum                                            $4.60
82943         Gluc                                                      $19.97
82944         Glucosamine                                                $3.46
82944   26    Glucosamine                                                $1.04
82944   TC    Glucosamine                                                $2.42
82945         Gluc Bdy Flu Oth/Thn Bld                                   $5.48
82946         Gluc Tolerance Tst                                        $21.06
82947         Gluc Quan Bld                                              $5.48
82948         Gluc Bld Rgnt Strip                                        $4.43
82949         Glucose; Fermentation                                      $6.56
82949   26    Glucose; Fermentation                                      $1.97
82949   TC    Glucose; Fermentation                                      $4.59
82950         Gluc Post Gluc Dose Gluc                                   $6.64
82951         Gluc Tolerance Tst Gtt 3 Spec Gluc                        $12.22
82952         Gluc Tolerance Tst Ea > 3 Spec                             $5.48
82953         Gluc Tolbutamide Tolerance Tst                            $21.16
82954         Glucose, Urine                                             $3.94
82954   26    Glucose, Urine                                             $1.18
82954   TC    Glucose, Urine                                             $2.76
82955         Gluc-6-Phosphate Dehyd Quan                               $13.55
82960         Gluc-6-Phosphate Dehyd Scr                                 $8.47
82961         Glucose Tolerance Test, Intravenous                       $26.06

                                             Page 179
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
82961    26   Glucose Tolerance Test, Intravenous                              $7.82
82961   TC    Glucose Tolerance Test, Intravenous                             $18.24
82962         Gluc Bld Gluc Mntr Dev Cleared Fda Spec Home Use                 $2.53
82963         Glucosidase Beta                                                $30.01
82965         Glutamate Dehyd                                                 $10.80
82975         Glutamine                                                       $22.13
82977         Glutamyltrase Gamma                                             $10.06
82978         Glutathione                                                     $19.91
82979         Glutathione Reduxase Rbc                                         $9.23
82980         Glutethimide                                                    $25.60
82985         Glycated Protein                                                $14.56
82995         Gold, Blood                                                     $22.32
82995   26    Gold, Blood                                                      $6.70
82995   TC    Gold, Blood                                                     $15.62
82996         Gonadotropin, Chorionic, Bioassay;                              $19.00
82997         Gonadotropin, Chorionic, Bioassay;                              $66.50
82998         Gonadotropin, Chorionic, Ria                                    $19.00
83000         Gonadotropin, Pituitary, Follicle Stimulating Hormone (Fsh);    $26.27
83000   26    Gonadotropin, Pituitary, Follicle Stimulating Hormone (Fsh);     $7.88
83000   TC    Gonadotropin, Pituitary, Follicle Stimulating Hormone (Fsh);    $18.39
83001         Gonad Follicle Stimulating Horm                                 $25.97
83002         Gonad Ltnzng Horm                                               $25.88
83003         Growth Horm Human                                               $23.29
83004         Growth Hormone, Human (Hgh) (Somatotropin); After Glucose To    $24.52
83004   26    Growth Hormone, Human (Hgh) (Somatotropin); After Glucose To     $7.36
83004   TC    Growth Hormone, Human (Hgh) (Somatotropin); After Glucose To    $17.16
83005         Guanase, Blood                                                  $18.05
83005   26    Guanase, Blood                                                   $5.42
83005   TC    Guanase, Blood                                                  $12.64
83008         Guanosine Monophosphate Cyclic                                  $23.45
83010         Haptoglobin Quan                                                $17.58
83011         Haptoglobin; Quantitative, Electrophoresis                      $16.95
83011   26    Haptoglobin; Quantitative, Electrophoresis                       $5.09
83011   TC    Haptoglobin; Quantitative, Electrophoresis                      $11.87
83012         Haptoglobin Phexyp                                              $24.02
83013         Hpylori Brth Non-Radact Isotope                                 $94.11
83014         Hpylori Drug Admn                                               $10.98
83015         Heavy Metal Scr                                                 $26.31
83018         Heavy Metal Quan Ea                                             $30.68
83019         Helicobacter Pylori, Breath Test (Including Drug And Breath     $88.80
83020         Hgb Fxj&Quan Electrophoresis                                    $17.99
83020   26    Hgb Fxj&Quan Electrophoresis                                    $20.06
83021         Hgb Fxj&Quan Chrom                                              $25.23
83026         Hgb Coppr Sulfate Meth Non-Auto                                  $3.30
83030         Hgb F Chem                                                      $11.56
83033         Hgb F Qual                                                       $8.33
83036         Hgb Glycosylated                                                $13.56
83040         Hemoglobin; Methemoglobin, Electrophoretic Separation           $15.02
83040   26    Hemoglobin; Methemoglobin, Electrophoretic Separation            $4.51
83040   TC    Hemoglobin; Methemoglobin, Electrophoretic Separation           $10.51
83045         Hgb Methgb Qual                                                  $6.93
83050         Hgb Methgb Quan                                                 $10.23
83051         Hgb Plsm                                                        $10.21
83052         Hemoglobin; Sickle, Turbidimetric                                $7.02
83052   26    Hemoglobin; Sickle, Turbidimetric                                $2.11

                                           Page 180
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
83052   TC    Hemoglobin; Sickle, Turbidimetric                                $4.91
83053         Hemoglobin; Solubility, S-D, Etc                                $11.03
83053   26    Hemoglobin; Solubility, S-D, Etc                                 $3.31
83053   TC    Hemoglobin; Solubility, S-D, Etc                                 $7.72
83055         Hgb Sulfhgb Qual                                                 $6.87
83060         Hgb Sulfhgb Quan                                                $11.56
83065         Hgb Thermolabile                                                 $9.62
83068         Hgb Unstable Scr                                                $11.83
83069         Hgb Urine                                                        $5.51
83070         Hemosiderin Qual                                                 $6.64
83071         Hemosiderin Quan                                                 $9.61
83080         B-Hexosaminidase Ea Assay                                       $23.57
83086         Histidine; Blood, Qualitative                                   $23.07
83086   26    Histidine; Blood, Qualitative                                    $6.92
83086   TC    Histidine; Blood, Qualitative                                   $16.15
83087         Histidine; Urine, Qualitative                                   $23.40
83087   26    Histidine; Urine, Qualitative                                    $7.02
83087   TC    Histidine; Urine, Qualitative                                   $16.38
83088         Histam                                                          $41.26
83090         Homocsteine                                                     $23.57
83093         Homogentisic Acid; Blood, Qualitative                           $14.03
83093   26    Homogentisic Acid; Blood, Qualitative                            $4.21
83093   TC    Homogentisic Acid; Blood, Qualitative                            $9.82
83094         Homogentisic Acid; Urine, Qualitative                           $10.04
83094   26    Homogentisic Acid; Urine, Qualitative                            $3.01
83094   TC    Homogentisic Acid; Urine, Qualitative                            $7.03
83095         Homogentisic Acid; Urine, Quantitative                          $16.50
83095   26    Homogentisic Acid; Urine, Quantitative                           $4.95
83095   TC    Homogentisic Acid; Urine, Quantitative                          $11.55
83150         Homovanillic Acid                                               $27.04
83485         Hydroxybutyric Dehydrogenase, Alpha (Hbd), Blood; Kinetic Ul    $13.03
83485   26    Hydroxybutyric Dehydrogenase, Alpha (Hbd), Blood; Kinetic Ul     $3.91
83485   TC    Hydroxybutyric Dehydrogenase, Alpha (Hbd), Blood; Kinetic Ul     $9.12
83486         Hydroxybutyric Dehydrogenase, Alpha (Hbd), Blood; Colorimetr     $8.48
83486   26    Hydroxybutyric Dehydrogenase, Alpha (Hbd), Blood; Colorimetr     $2.54
83486   TC    Hydroxybutyric Dehydrogenase, Alpha (Hbd), Blood; Colorimetr     $5.94
83491         Hydroxycorticostrds 17                                          $24.47
83492         Hydroxycorticosteroids, 17- (17-Ohcs); Gas Liquid Chromatogr    $30.15
83492   26    Hydroxycorticosteroids, 17- (17-Ohcs); Gas Liquid Chromatogr     $9.05
83492   TC    Hydroxycorticosteroids, 17- (17-Ohcs); Gas Liquid Chromatogr    $21.11
83493         Hydroxycorticosteroids, 17- (17-Ohcs); Blood, Porter-Silber     $22.32
83493   26    Hydroxycorticosteroids, 17- (17-Ohcs); Blood, Porter-Silber      $6.70
83493   TC    Hydroxycorticosteroids, 17- (17-Ohcs); Blood, Porter-Silber     $15.62
83494         Hydroxycorticosteroids, 17- (17-Ohcs); Blood, Fluorometric      $21.64
83494   26    Hydroxycorticosteroids, 17- (17-Ohcs); Blood, Fluorometric       $6.49
83494   TC    Hydroxycorticosteroids, 17- (17-Ohcs); Blood, Fluorometric      $15.15
83495         Hydroxycorticosteroids, 17- (17-Ohcs); Urine, Porter-Silber     $24.27
83495   26    Hydroxycorticosteroids, 17- (17-Ohcs); Urine, Porter-Silber      $7.28
83495   TC    Hydroxycorticosteroids, 17- (17-Ohcs); Urine, Porter-Silber     $16.99
83496         Hydroxycorticosteroids, 17- (17-Ohcs); Urine, Fluorometric      $26.15
83496   26    Hydroxycorticosteroids, 17- (17-Ohcs); Urine, Fluorometric       $7.85
83496   TC    Hydroxycorticosteroids, 17- (17-Ohcs); Urine, Fluorometric      $18.31
83497         Hydroxyindolacetic Acid 5                                       $18.01
83498         Hydroxyprogst 17-D                                              $37.95
83499         Hydroxyprogst 20-                                               $35.22

                                            Page 181
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                               Amount
83500         Hydroxyproline Fr                                          $31.65
83505         Hydroxyproline Tot                                         $33.96
83510         Hydroxyproline, Urine; Free And Total                      $62.00
83510   26    Hydroxyproline, Urine; Free And Total                      $18.60
83510   TC    Hydroxyproline, Urine; Free And Total                      $43.40
83516         Ia Anal Oth/Thn Nfct Agt Mlt Step Meth                     $16.12
83518         Ia Anal Oth/Thn Nfct Agt 1 Step Meth                       $11.85
83519         Ia Anal Quan Rp Tq                                         $18.88
83520         Ia Anal Quan Nos                                           $18.09
83523         Imipramine                                                 $21.97
83523   26    Imipramine                                                  $6.59
83523   TC    Imipramine                                                 $15.38
83524         Indican, Urine                                              $7.25
83524   26    Indican, Urine                                              $2.18
83524   TC    Indican, Urine                                              $5.08
83525         Insulin Tot                                                $12.72
83526         Insulin Tolerance Test                                     $18.63
83526   26    Insulin Tolerance Test                                      $5.59
83526   TC    Insulin Tolerance Test                                     $13.04
83527         Insulin Fr                                                 $18.09
83528         Intrnsc Factor                                             $22.22
83530         Inulin Clearance                                           $16.80
83530   26    Inulin Clearance                                            $5.04
83530   TC    Inulin Clearance                                           $11.76
83533         Iodine Protein Bound (Pbi)                                 $11.40
83533   26    Iodine Protein Bound (Pbi)                                  $3.42
83533   TC    Iodine Protein Bound (Pbi)                                  $7.98
83534         Iodine;Total                                               $15.20
83534   26    Iodine;Total                                                $4.56
83534   TC    Iodine;Total                                               $10.64
83540         Iron                                                        $9.05
83545         Iron, Serum; Automated                                      $9.87
83545   26    Iron, Serum; Automated                                      $2.96
83545   TC    Iron, Serum; Automated                                      $6.91
83546         Iron, Serum; Radioactive Uptake Method                     $10.82
83546   26    Iron, Serum; Radioactive Uptake Method                      $3.25
83546   TC    Iron, Serum; Radioactive Uptake Method                      $7.57
83550         Iron Bndng Cap                                             $12.21
83555         Iron Binding Capacity, Serum; Automated                    $13.28
83555   26    Iron Binding Capacity, Serum; Automated                     $3.98
83555   TC    Iron Binding Capacity, Serum; Automated                     $9.30
83565         Iron Binding Capacity, Serum; Radioactive Uptake Method    $12.77
83565   26    Iron Binding Capacity, Serum; Radioactive Uptake Method     $3.83
83565   TC    Iron Binding Capacity, Serum; Radioactive Uptake Method     $8.94
83570         Isocitric Dehyd                                            $12.36
83571         Isocitric Dehydrogenase (Idh), Blood; Colorimetric          $8.48
83571   26    Isocitric Dehydrogenase (Idh), Blood; Colorimetric          $2.54
83571   TC    Isocitric Dehydrogenase (Idh), Blood; Colorimetric          $5.94
83576         Isonicotinic Acid Hydrazide (Inh)                          $46.64
83576   26    Isonicotinic Acid Hydrazide (Inh)                          $13.99
83576   TC    Isonicotinic Acid Hydrazide (Inh)                          $32.65
83578         Kanamycin                                                  $23.00
83578   26    Kanamycin                                                   $6.90
83578   TC    Kanamycin                                                  $16.10
83582         Ketogenic Strds Fxj                                        $19.80

                                            Page 182
                          MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
83583         Ketogenic Steroids, Urine; 11-Desoxy: 11-Oxy Ratio              $34.99
83583   26    Ketogenic Steroids, Urine; 11-Desoxy: 11-Oxy Ratio              $10.50
83583   TC    Ketogenic Steroids, Urine; 11-Desoxy: 11-Oxy Ratio              $24.49
83584         Ketoglutarate, Alpha                                            $14.81
83584   26    Ketoglutarate, Alpha                                             $4.44
83584   TC    Ketoglutarate, Alpha                                            $10.37
83586         Ketostrds 17 Tot                                                $17.89
83587         Ketosteroids, 17- (17-Ks), Blood; Fractionation, Alpha/Beta     $42.50
83587   26    Ketosteroids, 17- (17-Ks), Blood; Fractionation, Alpha/Beta     $12.75
83587   TC    Ketosteroids, 17- (17-Ks), Blood; Fractionation, Alpha/Beta     $29.75
83588         Ketosteroids, 17- (17-Ks), Blood; Ria                           $26.27
83588   26    Ketosteroids, 17- (17-Ks), Blood; Ria                            $7.88
83588   TC    Ketosteroids, 17- (17-Ks), Blood; Ria                           $18.39
83589         Ketosteroids, 17- (17-Ks), Urine; Total                         $18.91
83589   26    Ketosteroids, 17- (17-Ks), Urine; Total                          $5.67
83589   TC    Ketosteroids, 17- (17-Ks), Urine; Total                         $13.24
83590         Ketosteroids, 17- (17-Ks), Urine; Fractionation, Alpha/Beta     $35.66
83590   26    Ketosteroids, 17- (17-Ks), Urine; Fractionation, Alpha/Beta     $10.70
83590   TC    Ketosteroids, 17- (17-Ks), Urine; Fractionation, Alpha/Beta     $24.96
83593         Ketostrds 17-Fxj                                                $36.75
83596         Ketstrds, 17-(17-Ks), Urine;D/A/F Ratio                          $0.00
83596   26    Ketstrds, 17-(17-Ks), Urine;D/A/F Ratio                          $0.00
83596   TC    Ketstrds, 17-(17-Ks), Urine;D/A/F Ratio                          $0.00
83597         Ketosteroids, 17- (17-Ks), Urine; 11-Desoxy: 11-Oxy Ratio       $29.52
83597   26    Ketosteroids, 17- (17-Ks), Urine; 11-Desoxy: 11-Oxy Ratio        $8.86
83597   TC    Ketosteroids, 17- (17-Ks), Urine; 11-Desoxy: 11-Oxy Ratio       $20.66
83599         Ketosteroids, 17-Oh, Ria                                        $22.10
83599   26    Ketosteroids, 17-Oh, Ria                                         $6.63
83599   TC    Ketosteroids, 17-Oh, Ria                                        $15.47
83600         Kynurenic Acid                                                  $33.15
83600   26    Kynurenic Acid                                                   $9.95
83600   TC    Kynurenic Acid                                                  $23.21
83605         Lactate                                                         $14.92
83610         Lactic Dehydrogenase (Ldh), Ria                                  $9.14
83610   26    Lactic Dehydrogenase (Ldh), Ria                                  $2.74
83610   TC    Lactic Dehydrogenase (Ldh), Ria                                  $6.40
83615         Lactate Dehyd                                                    $8.44
83620         Lactic Dehydrogenase (Ldh), Blood; Colorimetric Or Fluoromet     $8.08
83620   26    Lactic Dehydrogenase (Ldh), Blood; Colorimetric Or Fluoromet     $2.42
83620   TC    Lactic Dehydrogenase (Ldh), Blood; Colorimetric Or Fluoromet     $5.66
83624         Lactic Dehydrogenase (Ldh), Blood; Heat Or Urea Inhibition (     $8.35
83624   26    Lactic Dehydrogenase (Ldh), Blood; Heat Or Urea Inhibition (     $2.51
83624   TC    Lactic Dehydrogenase (Ldh), Blood; Heat Or Urea Inhibition (     $5.85
83625         Lactate Dehyd Isoenzymes Sep&Quan                               $17.88
83626         Lactic Dehydrogenase (Ldh), Blood; Isoenzymes, Chemical Sepa     $8.48
83626   26    Lactic Dehydrogenase (Ldh), Blood; Isoenzymes, Chemical Sepa     $2.54
83626   TC    Lactic Dehydrogenase (Ldh), Blood; Isoenzymes, Chemical Sepa     $5.94
83628         Lactic Dehydrogenase, Liver (Lldh)                              $10.28
83628   26    Lactic Dehydrogenase, Liver (Lldh)                               $3.08
83628   TC    Lactic Dehydrogenase, Liver (Lldh)                               $7.20
83629         Lactic Dehydrogenase (Ldh), Urine                                $8.48
83629   26    Lactic Dehydrogenase (Ldh), Urine                                $2.54
83629   TC    Lactic Dehydrogenase (Ldh), Urine                                $5.94
83631         Lactoferrin Fecal Quan                                          $27.42
83631   26    Lactoferrin Fecal Quan                                           $8.23

                                           Page 183
                           MERCY CARE PLAN - FEE SCHEDULE
Code    Mod   Description                                                    Amount
83631   TC    Lactoferrin Fecal Quan                                          $19.19
83632         Lactogen Hpl Human Chornc Somat                                 $28.24
83633         Lactose Urine Qual                                               $7.69
83634         Lactose Urine Quan                                              $16.10
83645         Lead, Screening; Blood                                          $13.61
83645   26    Lead, Screening; Blood                                           $4.08
83645   TC    Lead, Screening; Blood                                           $9.53
83650         Lead, Screening; Urine                                          $14.40
83650   26    Lead, Screening; Urine                                           $4.32
83650   TC    Lead, Screening; Urine                                          $10.08
83655         Lead                                                            $16.91
83660         Lead, Quantitative; Urine                                       $18.80
83660   26    Lead, Quantitative; Urine                                        $5.64
83660   TC    Lead, Quantitative; Urine                                       $13.16
83661         Ftl Lng Matrt Assmt L/S Ratio                                   $30.71
83662         Ftl Lng Matrt Assmt Foam Stability Tst                          $26.43
83663         Ftl Lng Matrt Assmt Fluorescence Polarization                   $26.43
83664         Ftl Lng Matrt Assmt Lamellar Bdy Dns                            $26.43
83670         Leucine Aminopeptidase Lap                                      $12.80
83675         Leucine Aminopeptidase (Lap), Blood; Colorimetric               $12.45
83675   26    Leucine Aminopeptidase (Lap), Blood; Colorimetric                $3.74
83675   TC    Leucine Aminopeptidase (Lap), Blood; Colorimetric                $8.72
83680         Leucine Aminopeptidase (Lap), Urine                             $11.04
83680   26    Leucine Aminopeptidase (Lap), Urine                              $3.31
83680   TC    Leucine Aminopeptidase (Lap), Urine                              $7.73
83681         Leucine Tolerance Test                                          $14.92
83681   26    Leucine Tolerance Test                                           $4.48
83681   TC    Leucine Tolerance Test                                          $10.44
83685         Lidocaine                                                       $21.26
83685   26    Lidocaine                                                        $6.38
83685   TC    Lidocaine                                                       $14.88
83690         Lipase                                                           $9.62
83695         Lipoprotein A                                                   $18.09
83700         Lipoprotein Bld Electrop Sep&Quan                               $15.73
83700   26    Lipoprotein Bld Electrop Sep&Quan                                $4.72
83700   TC    Lipoprotein Bld Electrop Sep&Quan                               $11.01
83701         Lipoprotein Bld Hr Subclasses                                   $34.68
83704         Lipoprotein Bld Quan Numb