for uninsured services - Saskatchewan Medical Association

SMA Fee Guide (for uninsured services)UPDATED APRIL 1, 2012Saskatchewan Medical Association402 - 321A 21st Street EastSaskatoon, SK S7K 0C1www.sma.sk.ca

TABLE OF CONTENTSIntroduction/PreambleI OverviewII Policy Statement on Third Party Requests and Uninsured ServicesIII DefinitionsIV General GuidelinesV Observations on Selected ServicesVI Unlisted ServicesVII Disputed FeesVIII Physicians’ Guide to Third Party Requests and Uninsured ServicesSection A1Section A2Section A3Section A4Uninsured ServicesI Charges Based on CostII Charges Based on Independent ConsiderationIII Response to a Request for Information by Third PartiesIV Medical-Legal ServicesServices Paid for by Provincial/Federal Agencies other than Medical Services Branch (MSB) atrates negotiated with the SMAThird Party Services paid by the Medical Services BranchGeneral ServicesSection BSection CSection DSection ESection FSection GSection HSection ISection JSection KSection LSection MSection NSection OSection PSection QSection RSection SSection TSection VSection WSection XSection YSection ZGeneral PracticePaediatricsInternal MedicinePsychiatryDermatologyMedical GeneticsAnaesthesiaCardiologySurgical AssistanceNeurosurgeryGeneral SurgeryOrthopaedic SurgeryPlastic SurgeryPhysical MedicineObstetrics and GynaecologyNeurologyUrological SurgeryOphthalmologyOtolaryngologyLaboratory MedicineDiagnostic UltrasoundDiagnostic RadiologyTherapeutic RadiologyNuclear MedicineCLASSIFICATION CODESEach procedure listed in the guide isassigned a classification code.DDiagnostic0 Day surgeryincludes the day of the procedure10 Day surgeryincludes the day of, and 10 daysfollowing, the procedure42 Day surgeryincludes the day of, and 42 daysfollowing, the procedureHand Surgery AppendixSMA Fee Guide

INTRODUCTION / PREAMBLEAn understanding of this preamble is essential for the proper interpretation of the GuideIOverviewThis Guide lists by Specialty Section, SMA recommended fees for uninsured medical services. For thepurposes of this Guide, uninsured medical services are those which are not paid by the SaskatchewanMedical Services Branch in accord with the Payment Schedule under The Medical Care Insurance Act.The services may be requested by the patient or by a third party interested in adjudicating the patient'sfitness or eligibility for certain benefits. It is inappropriate to bill the Medical Services Branch foruninsured services. The physician is entitled to charge either the patient for the service or the third partyrequesting the service. An appropriate record should be made of each uninsured service rendered.The Guide is not binding upon any physician. The Guide should be interpreted from the point of view thatit provides a tool for the determination of reasonable relativity between fees for services of averagecomplexity. It is assumed that physicians will, at all times, exercise responsible judgement in establishingtheir fees.The basic principle of the Guide is that a physician is entitled to appropriate compensation for servicesrendered. For circumstances where a fee might cause financial hardship to a patient, the physician maychoose to reduce the fee. Alternatively, when unusual time, skill, or attention is required in themanagement of any condition, the physician is entitled to a greater fee. In either case of individualadjustment, the physician is advised to provide the patient with an explanation.The Guide is divided into several sections with fee descriptions based as nearly as possible on thedescriptions listed in the insured payment schedule. Section A consists of three parts: (A.1) lists rates forgeneral uninsured services and third party requests; (A2) lists services that are negotiated with agenciesother than Saskatchewan Health Medical Services Branch; (A3) lists miscellaneous services thatcorrespond with Section A in the insured payment schedule. Other sections of this Guide are organizedby specialty, to be consistent with the insured Payment Schedule. This format is not intended to restrictany physician and, therefore, a physician who performs a service listed in another specialty section maybase the fee on the units listed in that section.IIPolicy Statement on Third Party Requests and Uninsured ServicesMost services provided by physicians are insured under The Medical Care Insurance Act or paid by otheragencies such as the Cancer Foundation, the Workers' Compensation Board, etc. Some servicesprovided by physicians are not insured. To clarify physicians' entitlements and responsibilities in thisregard, the Saskatchewan Medical Association maintains that:1. Physicians have a professional responsibility to expeditiously assist patients in obtaining thosebenefits to which they are legitimately entitled;2. Physicians are entitled to reimbursement for the extra time and resources devoted to the provision ofmedical information to third parties and for providing any uninsured service;3. Those parties requesting medical information, reports or certificates should be obliged to arrange forappropriate reimbursement;SMA Fee Guide - 1 - October 1, 2011

INTRODUCTION / PREAMBLE4. Third parties who request medical information about individuals must be clear as to why they requirethe information and tailor any forms accordingly after consultation with the SMA about the design oftheir forms;5. Third parties requesting information must ensure that the reason for the request is clearlycommunicated to the physician other than by word of mouth of the patient;6. When providing medical information, physicians should not be expected to judge whether the subjectpatient is eligible for the benefits provided by the third party;7. Physicians should not be considered by third parties as truant officers in dealing with absenteeism;8. In establishing fees for responses to third party requests and for uninsured services, physicians areguided by, but not bound by, the SMA Guide to Fees;9. The Association is prepared to facilitate adjudication of disputes over fees charged by physicians forthese services.III Definitions1. A visit is defined as the service by a physician to, or on behalf of, a patient. When more than onevisit is necessary on any given day, the physician is entitled to submit a fee for each servicerendered. The physician is entitled to charge appropriately for visit services when rendered in theoffice, the home, the hospital or wherever the patient may be at the time of the service.2. Hospital Care is defined as the professional services provided from the time of admission to the timeof discharge. Procedures, emergency visits and continuous personal attention prior to, or duringhospitalization command additional fees.3. Consultation applies where a physician who has attended a patient requests the opinion and adviceof another physician with respect to the diagnosis and/or management of the patient's currentcondition. The consultation includes the assessment of the patient, review of the relevant diagnosticdata and the submission of a written opinion to the referring physician. No follow-up care by theconsultant is assumed to be included in the fee for the consultation.4. Repeat Consultation is defined as a formal consultation for the same or related condition repeatedwithin 30 days by the same physician. A repeat consultation (service code 11), is only to be billedwhen it is generated by a new formal request by the referring physician. It should not be used forroutine follow-up of the patient for which a partial assessment or subsequent review (service code 5)or follow-up assessment (service code 7) are appropriate.5. Directive Care applies when the referring physician remains primarily responsible for the patient’scare, but, because of the seriousness or complexity of the condition, requests ongoing advice fromthe consultant during the acute phase of the illness.6. Multi-disciplinary care is the situation in which the complexity of the care, usually involving more thanone diagnosis, requires the services of more than one physician with complementary skills indifferent fields or practice for adequate care of the patient.7. Supportive care applies when the responsibility of the patient’s care has been temporarilytransferred by the referring physician to a consultant but it remains necessary and/or desirable forthe referring physician to visit the patient for the purposes of continuity and coordination of care aswell as support and reassurance for the patient and the family.SMA Fee Guide - 2 - October 1, 2011

INTRODUCTION / PREAMBLE8. Classification CodesAll procedures listed in the Guide are assigned a classification code as follows:D - Diagnostic - none0 - Day surgery - includes the day of the procedure10 - Day surgery - includes the day of, and 10 days following, the procedure42 - Day surgery - includes the day of, and 42 days following, the procedure9. Fee for Service - means services are to be billed on the basis of the individual appropriate visit orprocedure items.10. By report - means that the bill should be accompanied by a detailed explanation of thecircumstances and the services provided.IVGeneral Guidelines1. For the purposes of this Guide, a specialist is a physician whose name is listed as a specialist withthe Council of the College of Physicians and Surgeons of the Province of Saskatchewan.2. For physicians who have completed their specialty training and are awaiting placement on thespecialist register of the College of Physicians and Surgeons, it is suggested that they base theirfees on the fee listed for general practice or on 90% of that listed for the specialist, whichever is thegreater.3. When a general practitioner performs any service listed in a section of the Guide other than SectionsA1, A2 and B, H, and J, it is suggested that the fee be based on 90% of the listed fee without anasterisk (*). Codes with an asterisk (*) are considered to be single listed (i.e. the GP and specialistrates are the same).4. A physician may render a fee only for those services which have been provided or supervised aswell as the technical component of procedures performed in the office.5. A written report for a third party is a separate service for which the physician may render a fee inaddition to the fee for the medical service provided.6. A diagnostic, therapeutic or laboratory procedure performed or supervised by a physician commandsa fee in addition to the visit fee unless otherwise stated.7. When a procedure, either diagnostic or therapeutic, is the sole reason for the visit, it is suggestedthat the procedure fee alone be charged.8. When a procedure, either diagnostic or therapeutic, is performed in addition to an unrelated visitservice, it is suggested that the charge be the visit fee plus 75 percentage of the procedure fee.9. If, during any period of hospitalization, a patient develops an acute exacerbation of the illnesspresent on admission, a complication, or an entirely new and unrelated illness, the physician isentitled to charge hospital care as for a new admission.SMA Fee Guide - 3 - October 1, 2011

INTRODUCTION / PREAMBLESurgical Fees10. The concept of the composite surgical fee includes the base surgical procedure and associated careprovided to the patient in hospital following the procedure. All other services provided pre- and postoperativelyshould be billed separately.11. For diagnostic procedures related to the surgical procedure and performed by the same surgeon(e.g. cystoscopy, D and C, bronchoscopy, angiography) when done under the same anaesthetic asthe surgery or during the hospitalization following surgery, it is suggested that the fee be based onan individually selected percentage of the fees listed.12. If, during the post-operative period in the hospital, the patient develops a condition directly related tothe original disease and requires another operation, it is suggested that the fee be based on anindividually selected percentage of the fee(s) listed for the operation performed.13. If a patient develops a condition unrelated to the original disease while still in hospital, then anyprocedure performed commands the full fee.14. When two similar bilateral procedures are done at the same time or during the same admission tohospital, it is suggested that the fee for the second procedure be based on 75 percent of the listedfee unless otherwise listed.15. When one surgeon performs two or more unrelated procedures at the same time, through the sameor separate incisions, it is suggested that the fee for the lesser procedures be based on 75 percent ofthe listed fee unless otherwise listed.16. If a surgical procedure for which one fee is listed must be performed by two specialist surgeons, it issuggested that the attending surgeon bill according to the listed units and the second surgeonaccording to an individually selected percentage of the listed fee.VOBSERVATIONS ON SELECTED SERVICES1. Transfer of Medical ChartsRequests for information from the physician's office medical record may come from anotherphysician, from the patient, or from lawyers and other third parties. Each request merits a slightlydifferent approach.Requests from PhysiciansIt is rarely essential that a new physician obtain the patient's total file from previous attendingphysicians because most patients can recount the significant features of their past history.Therefore, a physician's request to another physician should state specifically what information isrequired, e.g. results of diagnostic procedures, therapeutic measures taken, response to therapy,etc. In such cases, the physician might consider sending a written statement.However, if a new physician sends a standard blanket request, the previous attending physicianhas two options: send a photocopy of the documents on file, or send the entire chart and ask the new physician to make copies as needed and then returnthe original file. (The physician should retain original files for a minimum of six years).There would, in most situations, be no charge for sending information to another physician.SMA Fee Guide - 4 - October 1, 2011

INTRODUCTION / PREAMBLERequests from PatientsThe Saskatchewan Health Information Protection Act (HIPA) enshrines patients’ rights to accesstheir own health information, and allows physicians to charge a “reasonable fee” for this access.When a patient asks for a copy of the medical record, one option is to suggest that the patienthave their new physician ask for specific information. If the patient requests his/her own personalcopy (and a growing number of patients are doing so), the physician should provide a photocopyand may charge the patient the fee(s) suggested in this Guide.Requests from LawyersWhen a lawyer requests a copy of the medical chart, the first step is to ensure that there is a validconsent signed by the patient to be placed on file. The next step is to offer to send a report toanswer the lawyer's specific questions.If that offer is not accepted by the lawyer, send a photocopy of the chart and charge the lawyer assuggested in the SMA Guide to Fees.It is helpful to remember that such fees are almost always passed on to the patient. The fee(s)charged to lawyers should not exceed what the patient would have been charged for directaccess to the information.The Health Information Protection Act requires that physicians (and other information trustees)respond to information requests in a reasonable time frame. Saskatchewan’s PrivacyCommissioner has informally defined “within 30 days” as a reasonable amount of time to respondto non urgent requests.2. Missed AppointmentsCharging for missed appointments is not a general occurrence but there are circumstances whichwould clearly justify such charges. It would be wise to forewarn each patient individually whencharges for missed appointments might be contemplated.3. Renewals of Prescriptions by TelephoneTelephone prescription renewals initiated by a pharmacist are considered to be an insuredservice (unless provided to a RCMP or other uninsured beneficiary).Patient-initiated telephone prescription renewals are considered to be uninsured. Practitionersare urged to exercise careful judgement when or if to charge for this service, as it is expected thatsuch charges may come under scrutiny.As with missed appointments, patients should be forewarned if a charge will be levied.4. Uninsured Services Provided at the Same Time as Insured ServicesIt can happen that, while assessing a patient at the request of a third party for an uninsuredservice, it becomes obvious that the patient requires medical care. Providing necessary medicalcare would be insured and it would be acceptable to submit a claim to the Medical ServicesBranch for those services. However, that portion of the service relating to compliance with thethird party's request such as completion of a report or certificate remains uninsured. Thephysician is entitled to charge separately for that.SMA Fee Guide - 5 - October 1, 2011

INTRODUCTION / PREAMBLEIt is expected that physicians will not charge for any of the following in addition to the insured feesfor any medical services provided: writing a prescription referral note to a colleague completion of a standard requisition form for a diagnostic or therapeutic service completion of patient records charges for any long-distance telephone calls related to referrals to colleagues may be billedto the patientVI Unlisted ServicesWhen no unit is listed for service and the service cannot be readily compared to one that is listed, thephysician may submit a request for a new listing to the SMA Committee on Uninsured Services throughthe office of the Saskatchewan Medical Association.VII Disputed FeesAll cases requiring advice regarding a dispute over fees or over the interpretation of this preamble shouldbe referred to the office of the SMA.VIII Physicians’ Guide to Third Party Requests and Uninsured ServicesTHE DIRECT BILLING PROCESS1. Ethics of Direct BillingThe Canadian Medical Association's Code of Ethics lists the principles of ethical behaviour forphysicians. One of these principles urges physicians to be "...responsible in setting a value onyour services".In this regard, the Code of Ethics states that an ethical physician: Will practise in a fashion that is above reproach and will take neither physical, emotional, norfinancial advantage of the patient. When acting on behalf of a third party will ensure that the patient understands the physician'slegal responsibility to the third party before proceeding with the examination. Will, upon a patient's request, supply the information that is required to enable the patient toreceive any benefits to which the patient may be entitled. Will consider, in determining professional fees, both the nature of the service provided and theability of the patient to pay, and will be prepared to discuss the fee with the patient.2. Some Practical GuidelinesThere are some practical guidelines physicians can follow when billing a patient directly to helpmake the process as comfortable and efficient as possible.SMA Fee Guide - 6 - October 1, 2011

INTRODUCTION / PREAMBLEa) Keep Patients Well-InformedAlways ensure that fees have been discussed with the patient before providing theservice. Most difficulties between a physician and patient arise from a lack of clearcommunication. Many patients simply do not realize that there are some services thegovernment does not pay for and they may become upset when presented with a bill.To prevent this from happening, physicians and their staff must ensure patients are wellinformedabout uninsured services and the direct billing policy well in advance of receivingtreatment.The following are a few suggestions on informing patients about direct billing.Clearly display in your patient waiting area a poster which outlines your billing policiesDiscuss fees when the patient books an appointment for an uninsured serviceMention fees before you provide the uninsured serviceProvide patients a fact sheet or pamphlet which includes information on direct billingb) Maintain simple and clear office policies and procedures for direct billingTo establish consistent office policies, physicians should first determine:Those services for which patients will be directly billedThe fees attached to those servicesAny exemptions, such as low income earnersBookkeeping and collection proceduresA physician's office policies on direct billing must be specific and detailed so that staff andpatients fully and clearly understand them. At the same time, they should allow sufficientflexibility to adapt to any unique or unexpected circumstances that may be encountered.Once office polices have been established, they should be put in writing and distributed tostaff members of the office staff. Procedures should be in place to apprise staff of anychanges to office policies.To minimize difficulties in direct billing, clinics should also: Maintain up-to-date accounts Collect payment from patients at the point of service as often as possible Follow-up in an orderly and consistent mannerc) Make adjustments for financial burdenWhen calculating fees, physicians should consider the financial burden such charges mightplace on the patient and be prepared to adjust fees based on these considerations.SMA Fee Guide - 7 - October 1, 2011

SECTION A1:UNINSURED SERVICESThe following is a categorized list of services for which physicians are entitled to charge, along with SMArecommended fees. The list is not exhaustiveICHARGES BASED ON COSTThis section includes services provided to patients for which reimbursement is calculated based on the actual costto the physician. The costs include the actual invoice cost, the applicable taxes plus staff time and otheroverhead costs.801A802A803A804ALong distance telephone calls on behalf of a patient ............................................................... COSTMedication by injection (hyposensitization serum, immunization, B12, etc.) ........................... COSTBandages, splints, IUD or other materials ............................................................................... COSTUninsured Tray services .......................................................................................................... COSTSMA Fee Guide A1April 1, 2012

SECTION A1:UNINSURED SERVICESIICHARGES BASED ON INDEPENDENT CONSIDERATIONTo determine a fee for third party or uninsured services, physicians may be guided by the fees listed in this Guide.To determine the fee for a service not listed in this Guide or to establish a fee independently, physicians mayconsider the following factors:• the nature and complexity of the matter• the experience and expertise required of the physician• time spent with and/or on behalf of the patient• the related office overhead costsServices with fees set on an individual consideration basis include, but are not limited to:• Preparation and transfer of a patient's health record at the request of the patient or the patient'srepresentative. The physician may charge for any time spent in preparing information for transfer in additionto the related office overhead• Surgery to alter appearance other than for abnormalities due to disease, trauma or congential defect• An anaesthetic service rendered for the provision of uninsured surgical or dental services• Acupuncture procedures• Routine examination of eyes over age 17• Electrolysis• Reversals of sterilization• Implantation of penile prothesis• Removal of minor skin lesions by cryo, laser, cautery or curettage (except actinic keratoses, pyogenicgranuloma, keratoacanthoma or bleeding lesions)• Dye tuned laser ablation of cutaneous lesions (except facial portwine stains in patients under age 18)• Injection of asymptomatic varicose veins and spider telangiectasia• Travel beyond the usual geographic area of practice to provide a medical service (insured or uninsured)• Services which are part of uninsured group screening programs• Visit or procedure services that are related to surveys or research• Providing or refilling a prescription by telephone when requested by the patient or the patient's representativeand no concomitant insured service is provided• Missed appointments for visits or procedures• Any other services or procedures which are not paid by Saskatchewan Health917AContinuous Personal AttendanceProfessional work other than direct patient care (includes administrative,advisory or committee work), and other than specific fees listed below- per 15 minutes (prorate if less) ..............................................................................................$60.00Photocopying patient records511A Photocopying/printing of records, base fee ..............................................................................$24.00512A - plus per page ...........................................................................................................................$0.60810A Physician time taken in reviewing the request/information and/or reviewing thechart if necessary per 15 minutes (prorate if less) ...................................................................$60.00Plus any mailing charges, which should be billed on a cost-recovery basis.Note: 810A should not be billed when patient has requested entire copy of the chart.SMA Fee Guide A2April 1, 2012

SECTION A1:UNINSURED SERVICES516AMissed appointmentsFor visit or procedure service(if 24 hours notice of cancellation not given) .................................................. Up to 50% of listed feeMedical Advice to a Patient517A - by telephone (including patient telephone prescription renewal)per 15 minutes (prorate if less) ..............................................................................................$60.00518A - by letter, per 15 minutes (prorate if less) ...............................................................................$50.00519A524A525ATime Spent on a Patient's Behalf- representation with an allied health professional, health carefacility, social service agency, etc.- per 15 minutes (prorate if less) ..............................................................................................$60.00- case conference- per 15 minutes or major portion thereof (917A) .....................................................................$60.00Physician Travel- by commercial carrier .............................................................................................................. Cost526A - by personal vehicle (per km) ................................................................................................$0.4125plus- time (per 15 min – 917A, prorate if less) ...............................................................................$60.00Telephone attendance55A - per 15 minutes (prorate if less) ..............................................................................................$60.00528AAcupuncture- per visit - per 15 minutes (prorate if less) ..............................................................................$60.00SMA Fee Guide A3April 1, 2012

SECTION A1:UNINSURED SERVICESIIIRESPONSE TO A REQUEST FOR INFORMATION BY THIRD PARTIESA third party service is defined as any service provided for a patient, which is necessary to satisfy the requirements ofa party other than the patient.1. A few third party services are paid for by the Medical Services Branch or by other agencies at negotiatedrates. These are listed in Sections A.2 and A.3 of this Guide.2. Other third party services which are not insured are also listed in the SMA Fee Guide. All medical servicesincluding assessments, examinations, diagnostic tests and/or reports for these requests are uninsured.Physicians are entitled to reimbursement for the time and resources devoted to the provision of theseservices. Examples of third party services include:Certification of Health Status For:• Admission to, or continued attendance in, day care, pre-school, elementary and secondary school,community college, technical institute, university or other educational institution• Admission to, or continued attendance in, a camp or recreational/athletic program• Issuing of a driver's, pilot's or other license• Obtaining or continuing employment: pre-employment or annual/periodic medicals• Meeting the requirements of provincial legislation or deriving the benefits of provincial health or socialprograms, e.g. community treatment services• Application for, or the continuation of, life, disability or other insurance coverage• Bank loan insurance• Injury report to CAHA• Assessment of claims for medical services abroad• Abilities Council special parking permit• Meeting the requirements of, or deriving the benefits of, certain services provided by health care facilities,e.g. out-patient dietary counselling, physiotherapy, etc.• Continuing Care Assessment Form or Instruction FormCertification of Illness for:• Sick slips for employment or return to work• Sick slips for school, day-care or recreation/athletic programs• Meeting the requirements of federal legislation or deriving the benefits of federal health or social programs,e.g. Employment Insurance., Canada Pension Plan, Canada Revenue Agency Disability Tax Credit,disability/maternity benefits• Entitlement to benefits under other disability insurance plans• Air fare cancellation• Student loan reliefVerification of death for:• Validation of a life insurance claimLegal reports and medical testimony in courtNote:Where the completion of a report requires a medical assessment of the patient, the physician is entitledto bill the appropriate visit fee plus a report fee to the third party (unless the services have been bundled,such as with the commercial drivers’ medical fee).SMA Fee Guide A4April 1, 2012

SECTION A1:UNINSURED SERVICESProviding Medical Information(The total fee for a report depends on the length of the form and the time taken to complete it)527APhotocopy of Medical Records- reply to an inquiry by submission of photocopy of a consultationor other written report ...................................................................................................... See 810A(This will not normally be charged when photocopies are attached towritten reports or report forms)529A - completion of form or brief written statement (per 15 minutes, prorate if less) .....................$60.00535A - written letter (per 15 minutes, prorate if less) ........................................................................$60.00Commercial Driver’s Medical805A - assessment plus form ..........................................................................................................$114.00806A - form only ................................................................................................................................$48.00SMA Fee Guide A5April 1, 2012

SECTION A1:UNINSURED SERVICESIVMEDICAL-LEGAL SERVICESIt is important to understand why a lawyer is asking for a medical report or a medical-legal opinion and specificallywhat information is required. If the lawyer's request is unclear, the physician should contact the lawyer to seekclarification. If payment for the report is not assured, the lawyer should be contacted prior to responding to therequest.1. Medical Reports560A - completion of form or brief statement (per 15 minutes, prorate if less) .................................$60.00561A - written letter (per 15 minutes, prorate if less) ........................................................................$60.00Note: This is a factual report on past health and/or current condition based on review of officeand/or hospital records submitted to a lawyer, insurance company or other third party.563A Medical-legal report ..............................................................................................................$480.00- if more than one hour of the physician's time, for eachsubsequent 15 minutes (prorate if less) add (917A) ..............................................................$60.00Note: This is a factual summary of the history, symptomatology, investigation, therapy, resultsand present condition. It may contain an estimate of the date that the person could returnto work and perhaps some comment as to the likelihood of permanent disability.564A Medical-legal opinion ............................................................................................................$540.00- if more than one hour of the physician's time, for eachsubsequent 15 minutes (prorate if less) add (917A) ..............................................................$60.00Note: This is a medical-legal report plus an expert opinion concerning such matters as:- cause and effect- long-term consequences- possible complications- extent, or percentage, disability- relationship of condition to factors in the work situationThis service involves the exercise of expert knowledge and judgement with respect tothe medical facts and findings including a detailed prognosis for the personaffected.2. Medical testimony in CourtThese codes are to be billed when Saskatchewan Justice tariff rates do not apply. Certain fees are paid bySaskatchewan Justice at rates negotiated with the SMA and prescribed in rules of Court (see page A12).i) Attending Physician566A - preparation time - per 15 minutes or major portionthereof (917A) ........................................................................................................................$60.00567A - court attendance or pre-trial briefing, first hour or part thereof ...........................................$420.00568A - time in court after the first hour, per quarter hour ...............................................................$102.00ii) Physician Called As Expert569A - preparation time - per 15 minutes or major portion thereof (917A) .......................................$60.00570A - court attendance - first hour or part thereof .........................................................................$540.00SMA Fee Guide A6April 1, 2012

SECTION A1:UNINSURED SERVICES571A - after the first hour, per quarter hour .....................................................................................$132.00572A - Failure to give two working days' notice of a court adjournmentor cancellation .....................................................................................................................$540.00Note:Out-of-pocket expenses for meals, accommodation and travel should bebilled in addition at cost.SMA Fee Guide A7April 1, 2012

SECTION A2:THIRD PARTY SERVICES AT RATES NEGOTIATED WITH THESASKATCHEWAN MEDICAL ASSOCIATIONThis section consists of services that may be requested by a variety of Provincial and Federal agencies. Theservices listed in this section are not insured under the Medical Care Insurance Act and are, therefore not paid byMSB. They are, however, paid for by the agencies who request these services at fixed rates negotiated with theSaskatchewan Medical Association. Unless otherwise noted, these services should be charged directly to theagency requesting the service.A. SASKATCHEWAN JUSTICE1. Appearance as a material witness for the Crown in criminal proceedings (effective January 1997)Testimony in courtFor first court appearance during fiscal year Spec GP589A - first hour or part thereof ............................ ....................................... .............. $175.00 $150.00- for each subsequent 15 minutes or major portion thereof, add (917A) .......... $40.00 35.00For subsequent court appearance590A - first hour or part thereof ............................ ...................................... ............... $200.00 $175.00- for each subsequent 15 minutes or major portion thereof, add (917A) .......... $45.00 40.00i. Payment for preparation, pre-trial briefing, waiting time and/ortravel time is included in the testimony fee.ii. When submitting your claim, please include a statement as towhether this is a first or "subsequent" appearance during the currentyear (April 1 to March 31). An increased fee will be paid forany subsequent testimony during that fiscal year. Fees for payment as an"expert" witness are negotiable.iii. Cancellation Notice ....................................................................... ............... $150.00 $125.00Failure to give notification of adjournment or cancellationto the practitioners' offices by noon of the work day prior to thedate of the scheduled court appearance (a "flat rate fee will be paid)Reimbursement of Expenses580A i. Meal allowances (At Public Service Commission rates)- breakfast ............................................................................................................................$8.00- lunch .................................................................................................................................$13.00- supper ...............................................................................................................................$17.00581A ii. Accommodation (max/night - receipt required) ...................................................................$65.00582A iii. Travel- commercial carrier (receipt required) ....................................................................... Cost- private vehicle, per km- below 54 th parallel ...................................................................................................$0.1750- above 54 th parallel .................................................................................................. $0.1886- taxi (receipt required) .......................................................................................................... CostMedical Documentation - requested by Lawyer583A (i) Letter .................................................................................................................................$100.00This is a factual report on past health and/or current conditionbased on review of office and/or hospital recordswhich summarizes of the history, symptomatology, investigation,therapy, and resultsSMA Fee Guide A 8April 1, 2012

SECTION A2:THIRD PARTY SERVICES AT RATES NEGOTIATED WITH THESASKATCHEWAN MEDICAL ASSOCIATION585A (ii) Report (opinion) ................................................................................................................$250.00This is an expert opinion concerning such matters as: causeand effect; long-term consequences; possible complications;and extent or percentage of disability. It involves the exerciseof expert knowledge and judgment including a detailed prognosis,and may contain some comment as to the likelihood of permanentdisabilityNote: Medical documentation fees are negotiable with the requesting lawyerif the report is complex.2. Appearance as a witness in a civil proceeding (effective January 1997)Payment arrangements in a civil proceeding should be discussed/negotiated with the lawyerrequesting your services. If a suitable fee cannot be agreed upon, you may be subpoenaedin which case the following rates will be paid for your appearance in court.Professional witness .......................................................................................... $100.00 per half dayConsultant to give expert testimony ................................................................... $200.00 per half dayA reasonable fee for preparation time and reasonable fee in the event of adjournmentor settlement of the action prior to testimony in Court is allowed at the discretion of thetaxing officer.If a medical report arising out of an examination is admitted in evidence, and the physician orsurgeon who made the report does not personally attend to give evidence, the fee payable to thephysician or surgeon who made the report is $200.00.Expenses will be paid on submission of receipts for necessary travel, accommodation and meals.Payment Arrangements:Provincial CourtIn Regina and Saskatoon submit claims for expenses, reports and court appearances to the prosecution officerequesting your services. In all other areas of the province submit your claims to the RCMP or city police officer whorequested your testimony.Court of Queen's BenchIn all areas across Saskatchewan submit your claims for expenses, reports and court appearance to the prosecutionoffice requesting your services.For information contact: Public ProsecutionsSaskatchewan Justice300-1874 Scarth StreetRegina, SK S4P 3V7Telephone: 306-787-5490SMA Fee Guide A 9April 1, 2012

SECTION A2:THIRD PARTY SERVICES AT RATES NEGOTIATED WITH THESASKATCHEWAN MEDICAL ASSOCIATIONB. POLICE SERVICESI. Investigation of Suspected RapeBill the MSB under Code 39 A for medical documentation and initial assessment and treatment.591A Additional time taken to gather and provide evidence for the ..................................................$45.00investigating officer - per 15 minutes or major portion thereof (917A)(Charge to the police officer’s local detachment)2. Collection of Sample for Blood Alcohol DeterminationAny medical services provided to a driver injured in a motor vehicle accident are insured by MSB.An additional fee for drawing a blood alcohol sample may be submittedto the local detachment of the investigating police officer as follows:592A Collection of blood sample and completion of forms for alcohol level determination ..............$55.00- plus 917A for any detention- plus appropriate surcharge when called specially to collect the sampleSMA Fee Guide A 10April 1, 2012

SECTION A2:THIRD PARTY SERVICES AT RATES NEGOTIATED WITH THESASKATCHEWAN MEDICAL ASSOCIATIONC. DEPARTMENT OF SOCIAL SERVICES - CHILD AND FAMILY SERVICES BRANCHAll services are paid at rates equivalent to Saskatchewan Justice fees for criminal proceedings.Submit to: Department of Social ServicesChild and Family Services Branch1920 Broad StreetRegina, SK S4P 3V6SMA Fee Guide A 11April 1, 2012

SECTION A2:THIRD PARTY SERVICES AT RATES NEGOTIATED WITH THESASKATCHEWAN MEDICAL ASSOCIATIOND. WORKERS' COMPENSATION BOARD (rates retroactive to April 1, 2012)Payments are made for certain services not listed in the MSB Payment Schedule:Reports650 - Initial (PPI) .............................................................................................................................$56.50651 - if submitted electronically by PPI template or typed clinical notescontaining similar information .........................................................................................add $11.90660 - Progress (PPP)......................................................................................................................$35.10661 - if submitted electronically by PPP template or typed clinical notescontaining similar information .........................................................................................add $11.90Complicated Consultations - (Specialists Only)119 a) conditions involving more than one area of the body, orb) chronic clients (those with injuries older than 12 weeks) .............................................add $90.30Special Opinion, on request97 (relationship of percentage of functional impairment) .....................................................add $226.00Research Fee (when requested by WCB) (per 10 minutes)178 - specialist ................................................................................................................................$45.20177 - general practitioner ................................................................................................................$40.70Telephone Consultations - initiated by the WCB or a health care provider currentlytreating the injured worker. Synopsis of the consultation to be included in patient’s chart.a) First 10 minutes:126 - specialist ...........................................................................................................................$45.201126 - general practitioner ...........................................................................................................$40.70b) 10 to 15 minutes:128 - specialist ...........................................................................................................................$60.201128 - general practitioner ...........................................................................................................$54.00c) Each additional 15 minutes:164 - specialist ...........................................................................................................................$60.201164 - general practitioner ...........................................................................................................$54.00179 RHCS4 – Treatment Implementation ....................................................................................$31.50Note: If received by the WCB within five days of the report request, an additional $26.00will be automatically added to the payment for this form.640 Counselling ............................................................................................................................$43.00- For patient counselling regarding early return-to-work, and/or completion ofreturn-to-work plan for work injuries expected to have temporary restrictions.- Billable for counselling sessions occurring at initial visit and maximum of onceevery four weeks thereafter that patient not engaged in return-to-work plan.- Must be documented in patient’s chart. Per 10 minutes or major portion.SMA Fee Guide A 12April 1, 2012

SECTION A2:THIRD PARTY SERVICES AT RATES NEGOTIATED WITH THESASKATCHEWAN MEDICAL ASSOCIATION199 Hospital Management ..........................................................................................................$119.00Billed by most responsible physician (MRP) and/or physician completing dischargesummary, for inpatient hospital stays. Includes discussion with patient regardingexpectations for recovery and return-to-work. Billed at or near time of discharge,with notation in patient’s chart. Per hospital stay.MEDICAL BOARDSTraumatic Brain Injury Consultation89 - Chair ...................................................................................................................................$942.001189 - Actual time spent in excess of 2.5 hours (per hour) .......................................................$377.00189 - Member ................................................................................................................................$753.001089 - Actual time spent in excess of 2.5 hours (per hour) .......................................................$301.00Cardiac (per hour)42 - Chair ....................................................................................................................................$377.00142 - Member ................................................................................................................................$301.00Cardiopulmonary – Medical Consultation5 - Chair ..................................................................................................................................$1130.001150 - Actual time spent in excess of 3 hours (per hour) ..........................................................$377.00150 - Member ................................................................................................................................$903.001050 - Actual time spent in excess of 3 hours (per hour) ..........................................................$301.00Medical Review Panel15 - Chair .................................................................................................................................$1,506.001115 - Actual time spent in excess of 4 hours (per hour) ..........................................................$377.001015 - Member .............................................................................................................................$1205.001215 - Actual time spent in excess of 4 hours (per hour) ..........................................................$301.00Medical Board190 - Member ................................................................................................................................$753.001190 - Actual time spent in excess of 2.5 hours (per hour) .......................................................$301.0085 Chaperone Fee (per 15 minutes) ............................................................................................$75.30Submit to: Workers’ Compensation Board200-1881 Scarth StreetRegina, SK S4P 4L1Toll-free Fax: 1-888-844-7773Note: The Workers’ Compensation Board reserves the right to withhold payment for incomplete or illegible reportsreceived.SMA Fee Guide A 13April 1, 2012

SECTION A2:THIRD PARTY SERVICES AT RATES NEGOTIATED WITH THESASKATCHEWAN MEDICAL ASSOCIATIONE. SASKATCHEWAN POWER800A Completion of Saskatchewan Power Practitioner’s Report Form P148 ...................................$40.00Please return forms and submit claims to:Submit to: Saskatchewan PowerReturn to Work10 SE, 2025 Victoria AvenueRegina, SK S4P 0S1Telephone: (306) 566-2416Fax: (306) 566-2406SMA Fee Guide A 14April 1, 2012

SECTION A2:THIRD PARTY SERVICES AT RATES NEGOTIATED WITH THESASKATCHEWAN MEDICAL ASSOCIATIONF. SASKATCHEWAN GOVERNMENT INSURANCE (SGI)FormsPractitioner’s (Initial Report)For a complete, legible report:- received within 30 days ..........................................................................................................$50.00- received within 7 calendar days after the visit or 14 days after request fromthe adjuster ............................................................................................................................$60.00Individual Written Rehabilitation Plan Form .............................................................................$20.00SGI Claimant Assessment Form .............................................................................................$20.00Practitioner Pre-assessment Form ..........................................................................................$20.00Case ConferencesThese will be paid as per the telephone consultation fees. Individual consideration willapply if travel outside the practitioner’s community is required.The physician should bill the adjuster for the call.Request for InformationTelephone Consultation:0 to 10 minutes ......................................................................................................................$20.0010 to 15 minutes ....................................................................................................................$38.50Each subsequent 15 minutes (917A) ....................................................................................$38.50Photocopy of Report/Consult .............................................................................. 10A/512A, page A2Form or brief ............................................................................................................... 529A, page A4Written letter - factual statement of patient’s condition .............................................. 535A, page A4Medical-legal report ..................................................................................................... 563A, page A4Medical-legal opinion .................................................................................................. 564A, page A4If preparation of the report for 563A or 564A requires more than one hour’s time, payment for additional time isbased on 917A.SGI officials are instructed to be very specific in their requests for reports and to indicate which code will bepaid. If the fee submitted exceeds the code indicated, the physician maybe asked for an explanation.Follow-up reports should be submitted directly to SGI and only on request from an SGI official. Lawyers mayobtain information from SGI.Submit to: Saskatchewan Government Insurance2260 - 11 th AvenueRegina, SK S4P 0J9SGI Driver Fitness ReviewNote: SGI will also reimburse physicians for requested drivers’ medicals. See Section A3.SMA Fee Guide A 15April 1, 2012

SECTION A2:THIRD PARTY SERVICES AT RATES NEGOTIATED WITH THESASKATCHEWAN MEDICAL ASSOCIATIONG. RCMP PERSONNEL (Effective April 1, 1987)RCMP Health Services pays at SMA Guide to Fees listed rates. The fee includes reporting the relevant clinicalfindings on the form which becomes part of the officer's medical file. Submit on RCMP Form 2135, ClinicalReport and Account Form to:Submit to: RCMP Health ServicesBox 6500Regina, SK S4P 3J7Telephone: 306-780-3836SMA Fee Guide A 16April 1, 2012

SECTION A2:THIRD PARTY SERVICES AT RATES NEGOTIATED WITH THESASKATCHEWAN MEDICAL ASSOCIATIONH. VETERANS AFFAIRS CANADADVA has declared that it will pay at Medical Services Branch Payment Schedule rates.Medical reports provided by a patient in support of a request for a benefit can be reimbursed at the followingrates if supported by a receipt/invoice from the physician.Source and Form of InformationPrescription only with no or only minor explanation, e.g. medicationrequired for lower back pain ........................................................................................................... NilPhone call with physician’s office (not physician) to obtain information ......................................... NilPhone conversation with physician ............................................................................. $10.00 per callOriginal report by family practitioner (FP) (one page); completion ofa form; subsequent report by a specialist ................................................................................$25.00Original report by a specialist (one page) ................................................................................$50.00Second and subsequent pages of a report, FP and specialist .................................................$20.00Copies of a physician’s notes or reports previously prepared for a third party ........ $15.00 first page($2.00 each additional page)Renewal of prescription by telephone (when fee not covered by province) ...............................$5.00Physician call to request authorization for special authorization benefitsDVA beneficiaries are only those veterans who have been declared eligible for a pension related to a specifieddisability.If there is any reason to believe that a veteran has been declared eligible, submit to DVA on the SaskatchewanBlue Cross form provided in your supplier kit.If the form is inadvertently sent to DVA and they are not responsible for the claim, they will forward it on to MSBrather than return it to you. If MSB receives a claim that is DVA responsibility, they will return it to you.If you want to register as a supplier or if you require billing forms, please contact Saskatchewan Blue Cross at1-800-301-6102, or in Saskatoon at 306-244-5839.Submit to:Veterans Affairs CanadaPO Box 6050Winnipeg, MB R3C 4G5Telephone: 1-866-522-2122SMA Fee Guide A 17April 1, 2012

SECTION A2:THIRD PARTY SERVICES AT RATES NEGOTIATED WITH THESASKATCHEWAN MEDICAL ASSOCIATIONI. CANADIAN FORCESThe Canadian Forces have declared that they will pay only at Medical Services Branch Payment Schedulesrates.Claims administration is handled through Saskatchewan Blue Cross, similar to the processes used for DVAclaims. If you require billing forms or further information, please contact Saskatchewan Blue Cross directly at:Saskatchewan Blue CrossP.O. Box 4030Saskatoon, SK S7K 3T2TelephoneToll-free: 1-800-301-6102Saskatoon: 306-244-5839SMA Fee Guide A 18April 1, 2012

SECTION A2:THIRD PARTY SERVICES AT RATES NEGOTIATED WITH THESASKATCHEWAN MEDICAL ASSOCIATIONJ. CANADA POST550APhysician’s Modified Work Information Sheet .................................................................... Use 529ASubmit to:Manulife Financial2220 Laurier Avenue West, Suite 400Ottawa, ON K1P 5Z9SMA Fee Guide A 19April 1, 2012

SECTION A2:THIRD PARTY SERVICES AT RATES NEGOTIATED WITH THESASKATCHEWAN MEDICAL ASSOCIATIONK. CANADA PENSION PLAN (effective August 1, 2010)CPP Disability Medical Report Form - The fee for completing the CPP Disability Form is a set fee. Completionof this six page form is paid at $85.00 (effective August 1, 2010). The level of the fee was set by CPP, based ona 40-minute estimated completion time.The Federal government has recently issued a new guideline to assist physicians in responding to a specificrequest from CPP to provide a narrative report in regard to a patient’s claim for disability benefits. The guidelineallows for payment up to a maximum of $150.00 for these reports. The following scale provided by CPP isintended to assist physicians in determining the appropriate fee.Billing for Medical ReportsSubmit invoices for services to CPP. Upon receipt of your invoice, CPP will reimburse you:553A Initial Medical Report .......................................................................................................up to $85.00554A Reassessment Medical Report .......................................................................................up to $25.00555A552A“Scanable Impairment Evaluation” and for the “Medical Report – Recurrenceof the Same Medical Problem” (ISP2525) ............................................................. up to $50.00 eachA very complete and detailed narrative report that involves more extensivechart review and medical report preparation .................................................................up to $150.00Note:• CPP has indicated that a faster payment will result if you note on your bill the time required to comply withthis request.• Physicians may still charge their patients for the difference between the CPP payment rate and thephysician’s normal charge for a similar service. (See codes 527A/535A)• Submit the bill to the patient who is expected to forward it to Health and Welfare Canada along with yourreport.• Occasionally, CPP requests independent medical consultations or functional capacity evaluations during theapplication process, or to determine continuing eligibility. CPP pays the specialist or facility directly for theseexaminations.• Fees mentioned in this section are set in consultation with the Canadian Medical Association and are subjectto change.SMA Fee Guide A 20April 1, 2012

SECTION A.3THIRD PARTY SERVICES PAID BY THE MEDICAL SERVICES BRANCHSGI Medical Driver Fitness ReviewThe services paid for listed on this page are paid by M.S.B. on anagency basis for SGI. These codes are not eligible for any additionalcharges, ( i.e.) premium(s) or surcharges.GP Specialist70A Telephone call from an SGI Driver Medical $30.00 * $30.00Review Unit or supervisor, requesting thephysician's clarification of a medicalcondition and affect on the patient'sability to operate a motor vehicleAll calls must be recorded on the patient's file chart,including the name of the SGI representative.71A Written letter or facsimilie requested by $55.00 * $55.00an SGI Driver Medical Review Unit orsupervisor, requesting a brief factualstatement of the patient's medicalcondition and effect on the patient'sability to operate a motor vehicleAll reports must be retained in thepatient's file.74A Examination and Report requested by the SGI Driver $75.00 $140.00Medical Review Unit requesting the physicians'sassessment of the patient's ability to operate amotor vehicleAll reports must be retained in the patient's file.No additional fee is paid for lab services required for74A with the exception of 131A.A visit provided on the same day as a 74A is paid by report.74A includes services described in 70A or 71A.70A, 71A and 74A are not payable for commercial license renewal.SMA FEE GUIDE - A21 - October 1, 2011

SECTION A.4:GENERAL SERVICESProceduresAdditional payments for diagnostic service excluding ECG's, 0, 10 or 42 dayoperative procedures performed on patients under one (1) year of age areautomatically calculated and paid as explained in Section A, Paediatric AgeSupplement for Procedural Fees.Fee20A Report requested by Saskatchewan Social Services $61.80 *to determine employability,rehabilitation potential, level of care,or other specified reason. The 20A and otherassociated visits and laboratory codes should besubmitted with a diagnostic code of Z90 (Examination -Third Party Request from SaskatchewanSocial Services)37A Examination and Report required for adoption -- child $126.00or parent or for a person becoming a foster parent-- a diagnostic code of V70 must be used39A Rape victim (suspected or actual) -- includes medical $934.00 *history, examination, counselling, all medicaldocumentation and initial treatment40A Child abuse victim (suspected or actual) -- includes $618.00 *medical history, history of abuse obtained from socialworker, police, parents or other individuals,examination, investigation and referral as necessary,counselling and treatment, medical documentation offindings and managementFoetal Alcohol Spectrum Disorder Assessment41A FASD assessment and diagnosis -- per 15 minutes $81.80 *or major portion -- (max of 12 units per patient)Clinical evaluation of the patient, review of information andconsultation with other providers (verbal and written) for thepurpose of Foetal Alcohol Spectrum Disorder (FASD)- assessment and diagnosis.Includes a review of:-- birth and prenatal history;-- medical and surgical histories, including psychiatric andpsychological reports;-- detailed family history focusing on genetic conditionswhich cause brain dysfunction;-- social history, including any social services records,pre-sentence reports, risk assessments, etc.Limited to physicians with appropriate training andexpertise in FASD assessment, including:-- geneticists with expertise in diagnosing birth defects;-- developmental paediatricians;-- any physician with training from a recognized trainingcentre for FASD diagnosis (examples University ofWashington, Seattle Washington; Lakeland Centre forFoetal Alcohol Syndrome, Cold lake Alberta; and theMotherisk Centre, Toronto).SMA FEE GUIDE- A22 -April 1, 2012

SECTION A.4:GENERAL SERVICESThe physician should keep appropriate documentationof time and place.Physicians who intend to provide this service should applyto the SMA Tariff Committee to be considered eligible tobill MSB for this service.(This code is not to be used for third party uninsuredrequests for assessment such as requests fromSaskatchewan Justice and others).Fee56A Report requested by Cancer Agency or $26.40 *Cancer Screening ProgramThe following 4 forms are covered under this fee code:1) Saskatchewan Cancer Agency request for follow-up ofregistered cancer patient - must be billed with a diagnositiccode from 140 to 2342) Program for the Prevention of Cervical Cancer - must bebilled with diagnostic code Z523) Screening Program for Breast Cancer - must bebilled with diagnostic code Z514) Colorectal Cancer Screening Program - must bebilled with diagnostic code Z5360A Required physician reporting forms $25.80The following form is covered under this fee code:1) Physician Reporting Form for West Nile cases - must bebilled with diagnostic code 066Exceptional Drug Status153A Multiple Sclerosis - payment for the completion $59.60 *and submission of the initial and yearlydocumentation required by the SaskatchewanDrug Program (SDP) to determine eligibility forExceptional Drug Status (EDS) in the treatmentof Multiple Sclerosis. Only one fee is payableevery twelve months. Applicable visit fees maybe submitted concurrently154A Alzheimers Disease - payment for the completion $59.60 *and submission of the initial documentationrequired by the SDP to determine eligibility forExceptional Drug Status (EDS) in the treatmentof Alzheimers Disease. Follow-up status reportsrequired by the Drug Program can be done byphone or fax and are billable using code 155A.Application visit fees may be submittedconcurrently155A Alzheimers Disease - follow-up status reports $23.80 *required by the SDP by phone or fax. Applicablevisit fees may be submitted concurrently156A Anklosing Spondylitis - payment for the completion $59.60 *and submission of the initial and renewal applicationform required by the Saskatchewan Drug Plan (SDP)to determine eligibility for Exceptional Drug Status(EDS) in the treatment of Ankylosing Spondylitis.Only one fee is payable every twelve months.Applicable visit fee may be submitted concurrentlySMA FEE GUIDE- A23 -April 1, 2012

SECTION A.4:GENERAL SERVICESFeeSpecified Forms752A SSCN prioritization form completion and $23.40 *submission to SSCN753A Physician completion and submission of an $31.40 *application filed with the court under theMandatory Testing and Disclosure (BodilySubstances) Act - by report909A Initiating protocol for the discontinuance of life-support $60.60 *systems following certification of brain death100A Collection of blood from donor for transfusion $32.00 *101A Phlebotomy for therapeutic reason $32.00 *e.g. polycythemia107A Insertion of IV by physician where a nurse or $32.00 *health care worker is unavailable or unableto start the IV - if procedure is longer than 15minutes, bill as 918A with explanation108A Venipuncture - peripheral or central (jugular) $44.20 *for blood collection or phlebotomy by physicianwhere a nurse or health care worker isunavailable or unable to perform the taskInjections -- medication extra110A -- intramuscular or subcutaneous - (included in visit) $32.00 *111A -- direct intravenous injection of medication (Not for $29.80 *injection into IV tubing nor for initiation if IV)112A -- arterial puncture $29.80 *113A Hyposensitization injections -- each -- included $13.90 *in visit maximum 3 units per session -- up to 9units per session for venom desensitization114A IVP/IVC injection when performed in the $29.80 *absence of a radiologist115A Aspiration and/or injection of ganglion $58.40 *116A Implantation of Norplant capsules $90.00 *for contraception117A Removal of Norplant capsules $122.00 *118A Pessary -- Initial fitting or review $40.80 *Bladder catheterization120A -- urethral $13.90 *121A -- other than urethral $20.60 *122A Peritoneal lavage $206.00 *123A Insertion of I.U.D. $100.00 *125A Paracentesis or diagnostic tap -- thorax $147.00 *or abdomen126A Pericardial aspiration - by any method $185.00 *(17 years of age and older)130A Pericardial aspiration - by any method $308.00 *(under 17 years of age)127A Lumbar puncture $123.00 *128A Gastric lavage $38.50 *129A Percutaneous manipulations of gallstone(s) $494.00 *131A Submission of Papanicolau smear (females only) $32.60 *132A Relief of faecal impaction -- under $147.70 *general anaestheticSMA FEE GUIDE- A24 -April 1, 2012

SECTION A.4:GENERAL SERVICESFee133A Pleural punch biopsy -- with or without $77.00 *thoracentesis134A Insertion of central venous catheter $118.00 *135A Insertion of central venous catheter in $234.00 *infant136A -- under general anaesthesia or IV sedation $326.40 *(includes post-op recovery)Insertion of arterial line for measurementof systemic pressures - unilateral or bilateral140A -- adult $75.60 *141A -- child $234.00 *137A Anoscopy $15.50150A Physiotherapy procedures including heat or $8.60 *light lamps, traction -- per treatment925A Intravenous chemotherapy or remicade $40.70 *treatment treatmentCommunicable disease service160A -- diagnostic skin tests (e.g. Schick $6.40 *test; Dick test) -- each161A -- immunization -- per injection $32.00 *(included in visit)162A -- vaccination and reading $32.00 *Allergy Diagnosis (Testing)170A Scratch test (inhalant-ingestant) - each $4.30 *-- maximum 35 units per annumPatch test (contact dermatoses)171A -- each $6.40 *-- maximum 50 units per annumIntradermal test172A -- each $7.60 *-- maximum 20 units per annumTest for phototoxic or photoallergicreaction under controlled ultraviolet lightsource (e.g. hot quartz mercury vaporlamp or Wood's Blak-Ray light)173A -- each $8.00 *-- maximum 30 units per annum174A Allergy Challenge--patient challenged with an $42.20antigen in a graded fashion (repeated spirometry264D + 2*265D can be billed - maximum 3 tests)(per complete 15 minute period)For hyposensitization -- See service code 113ATotal Parenteral NutritionWhen provided by other than the attendingphysician or surgeonNote: This service is included in visit/hospital carewhen provided by the attending physician or surgeon182A -- consultation and initial set up $270.70 *including CVP line183A -- subsequent care per day $30.20 *SMA FEE GUIDE- A25 -April 1, 2012

SECTION A.4:GENERAL SERVICESFee184A -- outpatient TPN supervision not payable with visit $30.20 *(max 2 per week)Botox InjectionsBotox fees below are intended for use in the relief of symptomsresulting from dystonias and other neuromuscular spasticityproblems and hyhidrosis.Entitlement to bill botulinum toxin injection codes is limited toOphthalmologists, Otolaryngologists, Orthopaedic Surgeons, Physiatrists,Internists, Neurologists, Plastic Surgeons, General Surgeons, Urologists,Gynaecologists and Anaesthetists. Others with appropriate trainingexperience may apply to the Saskatchewan Medical Association TariffCommittee for entitlement.Only one code from the Botox schedule is billable per patientcontact. Botox injections include any EMG control and additionalinjections within 42 days.190A Blepharospasm $372.00191A Hemifacial spasm $372.00192A Extraocular muscle(s) for strabismus or spastic $442.00dysphonia -- one or more muscles -- unilateralor bilateral (previously 473S)193A Multiple muscle -- bilateral $494.00194A Multiple muscle -- unilateral $372.00195A Single muscle -- bilateral $185.00196A Single muscle -- unilateral $123.00197A Rectal spasm, anal fissure $123.00Endoscopy for achalasia etc. -- see endoscopic codes - Section L.198A Hyperhidrosis -- per side (left or right armpit) - to $226.00intiate billing, two physicians must have diagnosed thepatient with hyperhidrosis (e.g. referring physician andconsultant, or two family physicians with the secondphysician confirming the diagnosis)199A Botox Injection of Detrusor Muscle via cystoscopy $372.00for neurogenic or non-neurogenic overactive bladderSpecimen collection and referral -- to be sent fora special test, when it is the only charge madeUrine204A Collection and referral of specimen(s) $11.20 *Blood205A Collection and referral of specimen(s) $11.20 *Other206A Collection and referral of specimen(s) $11.20 *Bone Marrow207A -- aspiration $93.60 *208A -- aspiration and needle biopsy $147.00 *209A -- interpretation $64.20 *210A Examination of blood smear and written $40.10clinical report -- by internist or paediatricianwith special training in haematologySMA FEE GUIDE- A26 -April 1, 2012

SECTION A.4:GENERAL SERVICESFeeCardiac Catheterization300A -- right heart catheterization - to include $295.30 *catheter insertion and any or all of RA, RV,PA, and PAW pressures. Not to be billedduring a routine coronary angiogram303A -- left -- retrograde includes catheter insertion $344.50 *and LV and AO pressures304A -- transeptal $380.90 *306A Transvenous endocardial biopsy (right or left) $660.00-- independent procedure307A -- when done in conjunction with any $200.00catheterization procedure, add310A Dye and/or thermodilution curve studies $190.50 *includes all curves obtained from a patientregardless of method311A Oximetry $190.50 *312A HIS bundle electrocardiography -- sinus $295.30node recovery time612A Complete electrophysiological cardiac $843.20studies with drug intervention613A Endocardial mapping $541.40614A Intracardiac electrocardiography and/or $215.10atrial pacing316A Insertion and measurements with Swan Ganz $319.90Catheter - to include all pressures, dye orthermodilution curves, recordings andinterpretationEchocardiographyEchocardiography is an insured service when it is provided by a physician who is listedby the College of Physicians and Surgeons of Saskatchewan as having qualified toreceive payment. Technical service is only billed if the physician owns the instrument.Multiple echocardiograms on a patient, except Doppler studies for patients under17 years of age, by same physician or clinic within a period of one year are paidat a reduced rate. The first interpretation is paid at 100%: the second at 50%; thirdand fourth at 25%, and for the remainder no fee is payable. The technical feesare paid at 100%. The first echo of any type performed starts theseries for that patient. Subsequent echos of any type are billed at the reducedrates. Although the physician may not be present for the entire exam,it is expected that he/she will be readily available when tests are being done.Serial Echocardiograms provided to patients receiving cardio-toxic onocologymedications at the request of the Cancer Agency will be considered for paymentat 100% for the first test in that 12 month period and each additional exam byreport at 100%.Example:Apr. 30, 2004 Interpretation of M Mode & 2 dimensional echocardiogram - claim 321A.May 15, 2004 Interpretation of M Mode & 2 dimensional echocardiogram - claim 521A.July 12, 2004 Interpretation of M Mode, 2 dimensional & doppler echocardiogram - claim 533A.Feb. 2, 2005 Technical & interpretation of M Mode & 2 dimensional echocardiogram - claim 530A and 531A.March 6, 2005 Interpretation of M Mode & 2 dimensional echocardiogram - No fee payable.May 4, 2005 Interpretation of M Mode & 2 dimensional echocardiogram (start of new series) - claim 321A.M Mode and Two - Dimensional same day320A -- technical (first) $154.10520A -- technical (second) $105.00530A -- technical (third and fourth, each) $105.00321A -- interpretation (first) $160.50521A -- interpretation (second) $80.30531A -- interpretation (third and fourth, each) $39.60SMA FEE GUIDE- A27 -April 1, 2012

SECTION A.4:GENERAL SERVICESFeeDoppler study, including M Mode plus twodimensionalstudies on same day322A -- technical (first) -- 17 years of age and older $196.90522A -- technical (second) -- 17 years of age and older $151.00532A -- technical (third and fourth, each) -- 17 years of $151.00age and older556A -- technical -- under 17 years $151.00323A -- interpretation (first) -- adult $258.90523A -- interpretation (second) -- 17 years of age $151.00and older533A -- interpretation (third and fourth, each) -- 17 years $108.00of age and older557A -- interpretation -- under 17 years of age $218.30535A -- technical for serial echocardiograms of $151.00patients receiving cardiotoxic oncologymedication (second and subsequent)536A -- interpretation for serial echocardiograms $216.00of patients receiving cardiotoxic oncologymedication (second and subsequent)Transoesophageal echocardiogram - to include insertion oftransducer and interpretation. Within one year at same officeor institution. The first and second transoesophageal echoesare paid at 100%, the third is paid at 25% and for remainderno fee can be charged.324A -- first and second $330.00534A -- third $82.40Codes 443A to 447A, 545A, 548A and 648A are not for useby Radiologists - see Section X.Angiography443A -- angiocardiography -- right and/or $258.90 *left side444A -- extremities, percutaneous $194.00 *-- unilateralAortography445A -- any method when sole procedure $301.70 *446A -- with selective catheterization of each $44.90 *additional artery to a maximum of 3, add545A --when done as part of 447A and/or $135.00 *443A or 145C, addCoronary Angiography to include right447A and left coronaries $461.20 *548A -- with selective catheterization of venous $160.50 *and/or arterial bypass grafts each toa maximum of 3, add648A -- with ergonovine stimulation, add $160.50 *Clinical procedures listed below associated with diagnosticradiology may be charged in addition to those listed in Section X.331A Intracoronary thrombolytic therapy $1,409.20SMA FEE GUIDE- A28 -April 1, 2012

SECTION A.4:GENERAL SERVICESFeeTransluminal angioplasty328A -- coronary $1,132.10329A -- each additional stenosis (maximum one $572.50per arterial branch)335A -- insertion of coronary artery stent(s) $440.80associated with 328A (any number), add332A -- pulmonary valve or artery $1,125.60333A -- pulmonary valve or artery where followed $572.50by corrective surgery within 24 hours334A -- Aorta or aortic valve $1,125.60493A Transcatheter closure of ductus arteriosis $1,243.30Note: Post-angioplasty care for elective procedures(328A, 329A, 334A and 493A) is included in thepayment for these procedures.Procedures under fluoroscopic, C.T. or Ultrasoundguidance are found in Section X.Procedures under fluoroscopic, C.T. or Ultrasonic guidance406A Percutaneous nephrostomy with nephrogram $600.00407A Manipulation of peritoneal dialysis catheter $112.00 *460A Non-palpable breast lesion - needle localization $102.00 *provided by surgeon412A Percutaneous fallopian tube cannulation and $250.00dilatation -- with selective salpingography,unilateral or bilateral463A Injection of a sinus tract $105.00403A Percutaneous intra-abdominal drainage $366.00462A Sialography $126.00 *661A Percutaneous insertion of pleural catheter for closed $175.00chest drainageContinuous Personal AttendanceThe benefit payment is all inclusive, for medically required personal attendance givencontinuously by a physician, where no other item in theSMA Fee Guide applies. Certainprocedures can be billed during a period of 918A, 926A-928A, 220A-226A in the same manner asthey can be billed during a period of 335H-339H. (For example if closedchest drainage takes 15 minutes, code 95L can be billed but that 15 minutes should notalso be billed as a 918A).These codes infer that a physician is continually present at a patient's bedside.Code 918A is not paid for maternity cases.For intensive care in ICU or CCU -- see Section H.For a claim to be processed, the physician must provide details of:I) the clinical condition neccesitating continuous attendance;ii) the treatment or care provided;iii) time when continuous attendance on patient started and was completed.May be billed with applicable surcharge where appropriate.918A Continuous personal attendance $84.60-- per 1/4 hour or major portion thereof(see requirements above)SMA FEE GUIDE- A29 -April 1, 2012

SECTION A.4:GENERAL SERVICESIndirect Patient Care = Emergency Situations = Emergency DepartmentFeeThis payment is for emergency situations in emergency departmentswhere physician time is spent exclusively on any of the following aspectsof patient care:(i) arranging hospital admisssion or transfer of the patient to anotheracute care facility(ii) arranging laboratory and diagnostic imaging services(iii) arranging the patient's surgical team(iv) coordinating acillary medical staffThis code is billable on the same day as countinous personal attendance (918A)and emergency resuscitation codes (220A-226A), provided that the time periodsdo not overlap. It is also billable following minor assessments, major assessmentsand consultations.The physician cannot bill for other work during the same time as this serviceis being billed. This code may only be billed by general practitioners.For a claim to be processed, the physician must provide details of:(i) the patient's clinical condition(ii) the type of care being arranged(iii) the time when indirect patient care was started and was completedMay be submitted with appropriate surcharge where applicable919A Indirect patient care -- per 15 minutes or major portion thereof $60.00(see reporting requirements above)Physicians accompanying a patient on transferby ambulance from one locale to anotherThese service codes are all inclusive, for medically required attendance during patient transferby ambulance. Certain procedures can be billed during a period of 926A-928Ain the same manner as they can be billed during a period of 335H-339H (see Section H).(For example if closed chest drainage takes 15 minutes, code 95Lcan be billed but that 15 minutes should not also be billed as a 926A or 927A).It may be billed with the apropriate emergency or special call surcharge.For a claim to be processed, the physician must provide details of:(i) the clinical condition necessitating continuous attendance(ii) the treatment or care provided(iii) time when continuous attendance on patient started and was completed926A Outbound journey with patient only -- per 15 minutes $96.20or major portion thereof927A Homeward or return journey with or without $55.20patient -- per 15 minutes or major portion thereof928A Standby at destination while patient is transferred $61.80 *to receiving physician (max of 4 units) -- per 15 minutesor major portion thereof725A Hospital discharge & documentation (payable $24.60 *once per discharge of formally admitted hospitalin-patients to the physician responsible fordischarging patient -- must be a location ofservice 2 and billed on the date of dischargefrom the hospital)Emergency Resuscitation - "Code" SituationsLife Threatening Emergency Situation - Being in constant attendance for thetime billed to provide resuscitation in an emergency situation (cardiac arrest,multiple systems major trauma, cardio respiratory failure, resuscitation of newborn,SMA FEE GUIDE- A30 -April 1, 2012

SECTION A.4:GENERAL SERVICESsevere shock, coma). The specific elements are those of an assessment, includingimmediate crisis related examination, on going monitoring of the patient'scondition and the usual resuscitative procedures as required: defibrillation,Feecardioversion, cutdowns, intravenous lines, arterial and/or venous catheters,pressure infusion sets and pharmacological agents, urinary catheters, CVP lines,blood gases, nasogastric tubes, endotracheal intubation and tracheal toilet.Time is to be measured as the period of constant attendance excluding timerequired for any separately billable intervention (service). If a physician startsbilling codes 220A to 223A, the resuscitation should finish with this series of codes.Amount payable per physician per life threateningemergency situation for the first two physiciansfor which a claim is submitted and paid220A - first 15 minutes $200.00221A - second 15 minutes $100.00222A - after first 30 minutes (per 15 minutes or $90.80major portion thereof)223A Amount payable per physician per life threatening $90.80emergency for third and subsequent physiciansfor which a claim is submitted and paid-- per 15 minutes or major portion thereofOther Resuscitation - is different from Life Threatening Emergency Situationonly in that it applies to providing resuscitation in emergency situations otherthan listed above and only includes the following resuscitative procedures:cutdowns, intravenous lines, arterial and/or venous catheters pressure infusionsets and pharmacological agents, urinary catheters, CVP lines, blood gases,nasogastric tubes, with or without lavage, and tracheal toilet. Time is to bemeasured as the period of constant attendance excluding time required forany separately billable intervention (service). If a physician starts billing codes224A to 226A, the resuscitation should finish with this series of codes.Amount payable per physician per OtherResuscitation for the first two physiciansfor which a claim is submitted and paid224A - first 15 minutes $100.00225A - after first 15 minutes (per 15 minutes or major $90.80major portion thereof )226A Amount payable per physician per other $90.80resuscitation for the third and subsequentphysicians for which a claim is submitted andpaid -- per 15 minutes or major portion thereofConsultation or assessment rendered before or after provision of resuscitativecare or neonatal intensive care may be claimed on a fee-for-service basis butnot when claiming Intensive (Critical, Ventilatory or Comprehensive) Care perdiem fees. When claiming Critical, Ventilatory, or Comprehensive Care per diemfees, no other Intensive Care codes may be claimed by the same physician(s).SPECIAL CALL SERVICES AND SURCHARGESA. Preamblel. Payment for a special call will be made only if the call is initiated by the patient,or someone other than the physician, on the patient's behalf.ll. Special call payments are claimable for where a physician attends a patient on a prioritybasis, and the visit causes a degree of disruption of work or of out of hours activity, and travel(except in the case of additional patients seen). When more than one patient is attended,SMA FEE GUIDE- A31 -April 1, 2012

SECTION A.4:GENERAL SERVICESthe surcharge for "additional patient" would apply. Please note - you cannot bill foradditional patients seen from 8 a.m. to 5 p.m. weekdays. Payment for a special call doesnot apply where a physician is specially called to another location in the hospital when heis already in the building.FeeSurcharges may apply to a service ata) the patient's home;b) hospital out-patient or emergency department;c) Special Care Home;d) physician's office when the physician is called back from some other place;e) other locations.lll. Payment will be made for the examination and/or procedure provided plus the appropriatesurcharge.lV. Where a surcharge is billed in connection with a major surgical procedure, fracture,dislocation or delivery, one surcharge is billable per case per physician.V. Special call services are categorized by time of day.Vl. "Weekend" refers to the period from 5:00 p.m. on Friday to midnight on Sunday."Statutory Holiday" refers to the entire 24 hour period of the specific day.Vll. The statutory holidays in each year are: January 1, Good Friday, Family Day(3rd Monday in February), Victoria Day, July 1, first Monday in August, Labour Day,Thanksgiving Day, Remembrance Day, Christmas and Boxing Day. If any of thesedays fall on Saturday or Sunday, they will be observed as stated in thePhysician's Newsletter.B. Special Callsl. Weekdays815A Surcharge -- 8 a.m. to 5 p.m. $77.40 *817A Surcharge -- first patient seen -- 5 p.m. to $113.00 *midnight (Monday - Thursday)837A Surcharge -- each additional patient seen -- 5 p.m. $56.00 *to midnight (Monday - Thursday)819A Surcharge -- first patient seen -- Midnight to 8 a.m. $264.00 *839A Surcharge -- each additional patient seen $76.00 *-- Midnight to 8 a.m.ll. Weekends and Statutory Holidays (or designated days)816A Surcharge -- first patient seen -- 8 a.m. to 5 p.m. $102.00 *836A Surcharge -- each additional patient seen $51.00 *-- 8 a.m. to 5 p.m.818A Surcharge -- first patient seen -- 5 p.m. to $138.00 *Midnight (Friday to Sunday)838A Surcharge -- each additional patient seen -- 5 p.m. $68.80 *to Midnight (Friday to Sunday)819A Surcharge -- first patient seen -- Midnight to 8 a.m. $264.00 *839A Surcharge -- each additional patient seen - Midnight to 8 a.m. $76.00 *lll. Emergency -- day or night -- any day721A -- Surcharge, in addition to payment for an $178.00 *appropriate assessment and/or procedureThis surcharge is payable where a physician travels to respondimmediately to a stat call involving a life-threatening situation,provides immediate care and arranges for the patient'semergency admission as a hospital in-patient.SMA FEE GUIDE- A32 -April 1, 2012

SECTION A.4:GENERAL SERVICESOn occasions where the factors in bold type pertain except thatemergency admission to hospital is not required,e.g. hypoglycemic shock, the physician is expected to providean explanation for billing this service code.FeeNote: Surcharge 721A is not payable when the patient is alreadyhospitalized.C. Surcharges are NOT billed in the following circumstances:(i) Where by prior arrangement, a patient may go to the out-patientdepartment of a hospital, in lieu of an office visit;(ii) A special call is initiated by the physician (except the house callsurcharges 615A or 915A);(iii) With codes 41A,153A-156A, 184A, 190A-199A, 600A, 626A,680A, 681A, 708A-718A, 725A, 726A, 727A, 752A, 753A,761A-769A, 790A-795A, 52B-53B, 60B-62B, 64B-68B, 130D,131D, 145D, 278D, 279D, 281D-291D, 300D, 320D, 500D,501D, 43E, 400H-424H, 667H, 100I, 80J, 81J, 278K, 279K, 31M,429N and 493N, 260P, 261P and 300T. These codes include allservices rendered as well as any travel;(iv) With hospital day care items, e.g. 25 to 28section B to T;(v) With emergency medicine visits (73B & 85B);(vi) SGI Medical Driver Fitness and Review (codes 70A to 73A);(vii) Extra patient surcharges are not paid with codes 335Hto 339H. Initial patient surcharges paid only onceper patient per day.Statutory Holiday Hospital Care Surcharge700A Premium payable for hospital care visit (25 to 28 B $20.00 *to T) or new born care visit (30, 31, 32 B or C) madeon a statutory holiday (day in lieu if stat is weekend).Bill as 700A in addition to the hospital care day code. The 700Ashould be billed at the same time as the hospital care visit.House Calls - Not Specially Called - Surcharges615A House Call -- follow-up visit, not specially called - surcharge $46.20 *915A House Call -- home care of cancer patient registered $46.20 *by the Saskatchewan Cancer Foundation - surchargePayment will be made for the examination and/or procedure provided plus either of thesurcharges 615A or 915A.The intent of payment under surcharge codes 615A and 915A is for a visit to a patient athome (not special care or nursing homes), where the visit is not initiated by the patientbut where the physician judges that a visit is required, e.g. a follow-up visit for a conditionseen previously, or a periodic visit for a chronic condition as in the case of a house-bound patient.Routine Nursing Home VisitThe fee is for a visit to a long term care facilityon a routine basis to evaluate the patient'scondition and to provide advice as necessary tothe patient and/or the nursing staff concerningthe management of the patient. The physicianmust either see and assess the patient or reviewthe patient's history and condition with nursingstaff. The physician needs to be able to verifythat the visit occurred.SMA FEE GUIDE- A33 -April 1, 2012

SECTION A.4:GENERAL SERVICESFee626A Patients in special care home, public nursing $52.60 *homes, respite beds, long term care facilitiesand Level 4 beds in hospital or health centres.Maximum payment of one visit per patient byany physician every 7 days.Where circumstances require that patients needmore than the above numbers of visits it is expectedthat the doctor will bill a partial assessment andfulfill all the requirements of that code. Wherea doctor visits a patient on a special call basis,payment will be at the special call rates dependingupon time of day, see Section A, Out-of-Hours PremiumsPrivate care facilities may be designated equalto the public nursing homes noted in thedescription above by the SMA Tariff Committee.Geriatric Assessment Unit600A Payment for assessment of patients attending $23.80 *Geriatric Assessment/Rehabilitation UnitPhysician must be physically present to consultand review patients as necessary. Documentationrequired for significant change orders only -- twoper patient per 7 day period.Group Counselling (instruction time only)680A Group Counselling of 5 or more patients where $117.00 *the objective is to provide medical expertiseregarding the patients' condition, to be billed inthe name of one patient -- initial 15 minutes.Claim must include a note or comment indicatingthe number of patient involved and the topic.681A -- additional complete 15 minute units (to a maximum of 3 units) $117.00 *Paediatric Age Supplement for Procedural Fees (including all diagnostic, 0, 10or 42 day procedure(s) including applicable section W and X codes but excludingECG's), surgical assistant and anaesthetic payment (codes 94H to 161H, 220Hand 500H to 505H).900A Patients less than 31 days of age, add 50 percent -- maximum of $1,500901A Patients less than 91 days of age but older than 30 days,add 25 percent -- maximum of $1,500902 A Patients less than 1 year of age but older than 90 days,add 10 percent -- maximum of $1,000Note: Paediatric Supplements are based on the value of the diagnostic service, 0, 10, or 42day procedure(s), surgical assist payment and the anaesthetic payment (codes 500Hto 505H only) (excluding all premiums and surcharges).Paediatric Weight Supplement for Procedural Fees-- (including all diagnostic, 0, 10 or 42 day procedure(s) including applicable section Wand X codes but excluding ECG's), in the case of the attending physician;-- the surgical assist payment in the case of the surgical assistant; and-- the anaesthetic payment (codes 500H to 505H only) in the case of the anaesthetist.You are required to submit the following codes to obtain the weight supplement if thehas not been reached by age.SMA FEE GUIDE- A34 -April 1, 2012

SECTION A.4:893A894A895AGENERAL SERVICESPatients greater than 30 days of age, less than 91 daysand less than 3kg in body weight --add 25%, maximum of $1,500Patients greater than 90 days of age and less than 3kgin body weight -- add 40%, maximum of $1,500Patients greater than 90 days of age and less than 6kgin body weight -- add 15%, maximum of $1,500FeeNote: Paediatric Weight Supplements are based on the value of the procedures listed above.In all cases time of day premiums and surcharges are excluded from the calculationof the supplement. If applicable bill as one of the above codes with the correctcalculated value (amount to be paid times the appropriate percentage) and indicatethe weight of the patient in a comment.Paediatric Age Supplements for visits with patients 0 to 5 years of age1. These supplements provide the physician with increased compensationwhen he provides an eligible visit service for a patient under 6 yearsof age.2. Eligible visit services include codes 3 to 11 sections C to T inclusive, 3B,4B, 5B, 9B, 11B, 15B, 73B, 85B, 38G, 39G, 14K, 15K, 12S, 9X and 10X.Other serivces are not eligible for this supplement.896A898AVisit supplement for patient 2 to 5 years of age - additional 20 percentVisit supplement for patients less than 2 years of age - additional 35 percentSpecialist Visit Supplement for patients 65 years of age and older1. These supplements provide the physician with increased compensationwhen providing an eligible visit service for a patient 75 years or ageor older.2. Eligible visit services include codes 3__, 5__, 7__, 8__, 9__, 10__ and11__ in sections C to T and 14K and 15K. Any other services are not eligiblefor this supplement.905A906AVisit supplment for patients 65 to 74 years of age - additional 15 percentVisit supplment for patients 75 years of age and older - additional 25 percentNote: Specialist Age Supplements are based on the value of the visitexcluding other premiums and surcharges.OUT-OF-HOURS PREMIUMS -- (to be referred to as a premium)1. Premiums(a) The premium provides the physician with increased compensation when heperforms most services in a non-office environment initiated between the hoursof 5:00 p.m. and 7:00 a.m., weekends or on a statutory holiday.(We have a lot of detail in the location that the PS does not have - I removed)2. The service must be provided in a location other than the office,or an alternate office, to be eligible. Services not eligible for an out-of-hours premium include:(a) hospital visits (25 to 28B to T, 700A, 52B, 53B);(b) surcharges, e.g. 815 to 839A, 615A, 721A, 915A;(c) emergency room coverage services, e.g. 708-718A;(d) special care homes and nursing home code, ie. 626A;(e) lab services;(f) services always done in the office, e.g. 320A, 322A, 520A, 522A, 530A,532A, 535A, 556A, 4B, 4C, 30D, 32D, 50D, 54D, 65D, 142D, 267D, 269D,271D, 276D, 320D, 401D, 13G, 897L, 899L, 31M, 260P, 261P, 330P, 338P,438P, 439P, 109Q, 29R, 402R, 404R, 406R, 15S, 40S, 45S, 181S, 301S, 535S, 579S,651S, 653S, 582S, 96T, 300T, 443T,(g) other services 41A, 56A, 60A, 65A, 70A-74A, 153A-155A, 184A, 190A-198A, 600A,680A, 681A, 725A, 726A, 727A, 732A, 734A, 752A, 753A, 761A-769A,790A-795A, 57B, 60B-62B, 64B-68B, 145D, 121D, 123D, 124D, 128D-132D,SMA FEE GUIDE- A35 -April 1, 2012

SECTION A.4:GENERAL SERVICES278D, 279D, 281D-291D, 300D, 500D, 501D, 43E, 400H-424H, 540H,545H, 580H, 585H, 80J, 81J, 278K, 279K, 679K, 580L, 180M, 492N-494N,580P, 581P, 400R, 500R, 580R3. Services must start in the time period 5:00 p.m. to 7:00 a.m. or anytimeon a weekend or statutory holiday to qualify for the premium.4. Out-of- hours premium for obstetrical delivery is paid if the time of delivery falls between5:00 p.m. and 7:00 a.m. or anytime on a weekend or statutory holiday.5. The out-of-hours premium will apply to time units (e.g. H and J codes) extending beyond7:00 a.m. as long as the service began within the 5:00 p.m. to 7:00 a.m.time period, or anytime on a weekend or statutory holiday.6. An out-of-hours premium may be billed for services in locations 2, 3, 4, or 5:(a) where an out-of hours premium applies to these services at those locations for5:00 p.m. to midnight, or 7:00 a.m. to midnight on weekends and statutory holidays,they must be billed with a location of service of B (in-hospital), C (out-patient), D (home),or E (other), respectively.(b) where an out-of-hours premium applies to these services at those locatrions formidnight to 7:00 a.m., they must be billed with a location of service of K (in-hospital),M (out-patient), P (home), or T (other), respectively.7. An out-of-hours premium starting before midnight (5 p.m. To midnight) andrunning into the next day should be billed at the before midnight rate.8. Effective April 1, 2012 the rates are 50% for 5:00 p.m. to midnight weekdays,weekends and statutory holidays; 7 a.m. to 5:00 p.m. weekends and statautory holidays, and100% for midnight to 7:00 a.m. weekdays, weekends and statutory holidays.After-Hours-Clinic Premium1. The after-hours-clinic premium provides the physician with increased compensationwhen he performs most services in a office location outside the hours of 7:00 a.m. And7:00 p.m. weekdays.2. The premium applies to scheduled or unscheduled after-hours-clinic work.3. This premium is restricted to general practice physicians in Moose Jaw, Prince Albert,Regina, and Saskatoon.4. The service must be provided in an office location to be eligible. Services not eligiblefor an after-hours-clinic premium include:(a) hospital visits (25 to 28B to T, 35B, 700A, 52B, 53B)(b) surcharges, e.g. 815 to 839A, 615A, 721A, 915A(c) emergency room coverage serviced, i.e. 708A to 718A(d) special care homes and nursing home code, i.e. 626A(e) lab services(f) services always done in the hospital, e.g. 184A, 600A, 725A, 726A, 727A, 732A,734A, 121D, 123D, 124D, 128D-132D, 278D, 279D, 281D-291D, 500D, 43E, 400H-424H,540H, 545H, 580H, 585H, 80J, 81J, 278K, 279K, 679K, 580L, 180M, 580P, 581P, 400R, 500R(g) SGI 70A, 71A, 74A(h) other services 57B, 60B, 61B, 62B, 763A, 764A, 765A, 767A, 768A5. When an after-hours-clinic premium applies to these services at an office location theymust be billed with a location of service of F (after-hours-clinic).6. Effective June 1, 2011 the rate is 10% for weekdays 7:00 p.m. To 7:00 a.m., weekendsSMA FEE GUIDE- A36 -April 1, 2012

SECTION A.4:GENERAL SERVICESand statutory holidays. For this premium "Weekend" refers to the period from 7:00 p.m.on Friday to midnight on Sunday. "Statutory Holiday" refers to the entire 24-hour periodof the specific day.Telephone Calls/Facsimile/E-mail(for prescription renewals see codes 794A-795A)Telephone call initiated by allied health care personnelto discuss patient care and management - maximum of one perpatient per day (codes 790A to 795A)Allied health care personnel includes, but is not limited to:-- Home care coordinators -- Registered and licenced practical nurses-- VON -- Public health nurses-- Psychiatric nurses -- Mental health workers-- Physiotherapists -- Occuptional therapists-- Respiratory Therapists -- Ambulance Paramedics-- Social workers -- Psychologists-- School teachers/counsellors -- Pharamacists-- Private care home shift supervision-- Payment is for telephone conversations initiated by allied healthcare workers.-- All calls must be recorded on the patient's chart, including the name andprofessional capacity of the health care worker involved and the advice given.-- No claim may be made for telephone calls in which only a physician proxy,e.g. nurse or clerk, speaks with the allied health care personnel.-- No claim may be made for telephone calls regarding patients in hospitalreceiving acute care.-- This service is not intended to cover calls insured as part of the Emergency roomcoverage codes (708A to 716A in the MSB Payment Schedule).-- This service is intended to compensate the physician for unexpectedinterruptions to the physician's normal practice routine.-- Where the allied health worker requests information or advice by facsimiletransmission or electronic mail, the physician may respond by telephone,fax or electronic mail and submit a claim for this request.-- Only one of codes 790A-795A should be billed per day.On behalf of nursing home patients790A Phone/Fax/E-mail -- Not payable in addition to any other $24.60 *payment for the same date of serviceOn behalf of all other patients791A Phone/Fax/email -- Not payable in addition to any other $24.60 *payment for the same date of serviceTelephone Calls/Facsimile/E-mail on behalf of a palliative patientThis code is billable for patients designated as palliative by their Regional HealthAuthority or by the Saskatchewan Drug Plan.Billing is restricted to telephone calls, facsimile or email initiated by allied healthcare personnel, or telephone calls from the patient's designated family representatives.Allied health care personnel includes, but is not limited to: Home Care Coordinators;Registered and Licenced Practical Nurses; VON; Public Health Nurses; Psychiatric Nurses;Mehtal health workers; Physiotherapists; Occupational Therapists; Respiratory Therapists;Ambulance Paramedics; Social Workers; Psychologists; School Teachers/Counsellors;SMA FEE GUIDE- A37 -April 1, 2012

SECTION A.4:Pharmacists; Private care home shift supervisor.GENERAL SERVICESNo claim may be made for telephone calls in which only a physician proxy, e.g. nurseor clerk, speaks with the allied health care personnel or family members. No claimmay be made for telephone calls regarding patients in hospital receiving acute care.FeeWhere the allied health personnel requests information or advice by facsimile,e-mail, or other electronic means, the physician may respond by telephone, facsimile,e-mail, or other electronic means. Contacts from the patient's family representativeare restricted to telephone calls.All interactions must be recorded on the patient's chart, including the name andprofessional capacity of the allied health care personnel involved and the advice given.A maximum of three contacts are payable per day. Codes 790A and 791A are notbilliable for this patient on the day this code is billed.793A Telephone calls/facsimile/e-mail on behalf of palliative patient $24.60Prescription renewal by telephone call, facsimile, e-mail or otherelectronic meansTelephone call pharmacist initiated for the purpose of refilling aprescriptionPrescription Renewal Phone Call794A Phone call -- Not payable in addition to any other $9.80 *payment for the same date of servicePrescription Renewal Fax/E-mail795A Fax call -- Not payable in addition to any other $9.80 *payment for the same date of serviceRemote Telephone call from Primary Health Nurse/TriageNurse in another community761A Not payable in addition to any other payment $40.00 *for the same date of service (max per day - 1call per patient)Additional calls or visits will only be paid byreport. Payment is restricted to telephoneconversations initiated by remote primary healthnurse/triage nurse seeking advice about themanagement of a patientAll Calls must be recorded on the patient's chartincluding the name of the primary healthnurse/triage nurse involvedRemote Consultations Between PhysiciansMajor Telephone Assessment and Advice769A includes: pertinent family history, patient history, $99.00history of presenting complaint, discussion withreferring physician of functional enquiry andexamination of all parts and systems, review oflaboratory and/ or other data, diagnosis/ assessmentrecord and written submission of the consultant'sopinion and recommendations to the referringdoctor, but without the consulting physician seeingthe patientSMA FEE GUIDE- A38 -April 1, 2012

SECTION A.4:If the patient is subsequently seen within 42 daysfor care or assessment, the physician would beunable to claim for a consultation, but couldclaim for a complete or initial assessment,depending upon the service providedGENERAL SERVICESFeeMinor Telephone Assessment and Advice762A includes: history review, history of presenting $40.00complaint, discussion of patient condition/management and advice to referring physicianbut without the consulting physician seeing thepatientA written opinion is not necessary for this fee.However, the referring physician's name, patientInformation, the diagnosis and the advice givenmust be recorded.Where a General Practitioner requests informationor advice by facsimilie transmission or electronicmail, the Specialist may respond by telephone, faxor electronic mail and submit a claim for thisserviceMonitoring Anticoagulant Therapy763A Monitoring anticoagulant therapy by telephone, $24.60 *per month -- monitoring the condition of a patientwith respect to anticoagulant therapy, includingordering blood tests, interpreting the results,inquiry into possible complications and adjustingthe dosage of the anticoagulant therapy.Max patient per month (only one physician canbe paid for each month)Management of DiabetesMonthly fees for monitoring and managing patientswith insulin-dependent diabetes. Includes monitoringpatient's condition, blood sugars and insulin levels;ordering and interpreting any necessary tests;adjusting insulin dosage as necessary.The fees are only payable for months during which thepatient has sent information to the physician (by phone,fax, e-mail or other electronic means) that requires achange in the patient's drug or insulin therapy. Thephysician must review the information personally (notbillable if review undertaken by nurse or diabetes educator).Only one physician may bill these codes for any givenpatient in any one month. A record of the informationand the physician's advice must be included in thepatient's chart.764A Patients with Type 2 Diabetes on Insulin, per month $45.40 *765A Patients with Type 1 Diabetes on Insulin, per month $91.00 *SMA FEE GUIDE- A39 -April 1, 2012

SECTION A.4:GENERAL SERVICESFeePatients with Type 1 Diabetes on Insulin Pump766A -- first 12 months, per month $136.00 *767A -- after 12 months, per month $91.00 *768A Pregnant Patients with Diabetes (Type 1 or 2) on $136.00 *insulin, per monthTelemedicine Supplement with Direct InteractiveVideo Link with the Patient732A Initial daily supplement for any patient attended $61.60 *to using an approved telemedicine video link(maximum of one per day for all patients)734A Subsequent daily supplement for additional $24.60 *patients attended to using an approvedtelemedicine video link- Payable in addition to appropriate visit codes only.Premiums and special call surcharges do not applyto these telemedicine codes.- On site assistant may be needed to assist with the on siteaspects of the assessment (examination).Telemedicine Technical Standy729A -- for each 15 minutes, or major portion thereof $61.60 *(max 30 minutes)Only applies if telemedicine service is delayed orinterrupted for technical reasons.- No other service can be provided or billed in this interval.- Paid by report. (Please detail the nature of the problemand its resolution).- The time is calculated from the beginning to theend of the technical delay.General Practice Assistant Service. Only applies if ageneral practitioner is required at the referring end, toassist with essential physical assessment without whichthe specialist service would be ineffective.- The time is calculated fro the beginning to the end of thepersonal attendance.- No other service can be provided or billed in this interval.- Intervals of more than 30 minutes must include anexplanation.General Practitioner Assistant728A -- for each 15 minutes, or major portion thereof $61.60Video Case ConferenceMust be a formal scheduled session with anapproved out-of-province referral centre. A singlevideo case conference fee billed in the name ofone patient covers all the patients reviewedduring that videoconference. The physicianshould keep appropriate documentation of timeand place. Entitlement to bill video caseconference codes is limited to physicians whohave applied to and been granted approval bythe Saskatchewan Medical Association TariffCommittee.SMA FEE GUIDE- A40 -April 1, 2012

SECTION A.4:GENERAL SERVICES726A First 15 minutes $103.00 *727A -- subsequent 15 minutes, or major portion $70.60 *SMA FEE GUIDE- A41 -April 1, 2012

SECTION B:GENERAL PRACTICEGeneral Practice VisitsFeeVisit age supplement for patients 55 years ofage and older:1. These supplements provide the physician withincreased compensation when providing aneligible visit service for a patient over 54 years of age.2. Eligible visit services include codes 3B, 5B, 9B,11B and 15B. Any other services are not eligible forthis supplement.100B for patients 55 to 64 years of age 15 percent101B for patients 65 to 74 years of age 25 percent102B for patients 75 years of age and older 35 percentNOTE: General Practice Age Supplements arebased on the value of the visit excluding otherpremiums and surcharges.3B Complete assessment $130.00-- includes: pertinent family history, patienthistory, history of presenting complaint, functionalenquiry, examination of all parts and systems,assessment, diagnosis, necessary treatment,advice to patient and record of service provided5B Partial assessment or subsequent visit $66.40--includes: history review, history of presentingcomplaint, functional enquiry, examination ofaffected part(s) or system(s), assessment, diagnosis,necessary treatment, advice to the patient and recordof service provided4B Well baby care in office $71.40-- refers to the periodic office visits during thefirst year of life of a healthy infant andincludes the necessary weights andmeasurements, examination and instruction tothe parent regarding health care8B Pre-natal visit after the first visit for maternity care $71.40or post-natal office visit9B Consultation $143.00-- includes all visits necessary, history andexamination, review of laboratory and/or otherdata and written submission of the consultant'sopinion and recommendations to the referringdoctor11B -- repeat consultation $71.4015B Pre-operative assessment $131.00-- includes: pertinent family and socialhistory, patient history, functional enquiry,examination of all relevant parts and systems,completion of required forms and advice tothe patient as necessary (payable only tophysicians other than the attendingsurgeon)Where this service is provided by the samephysician within 30 days of a completeassessment it should be billed as a partialassessment.SMA FEE GUIDE - B1 - April 1, 2012

SECTION B:GENERAL PRACTICEFee63B Examination and certification of need for psychiatric $147.70examination pursuant to The Mental Health Services Actwith completion of Form ANote: Code 63B does not apply to examination, certification or decertification formental incompetence/competence under the Mentally Disordered Persons Act.Accounts for those services should be submitted to the office of the Public Trustee.CounsellingCounselling is where the physician engages with the patient on an individualbasis, where the goal of the physician and patient is to become aware of thepatient's problems or situation and of the modalities for prevention and/ortreatment. Counselling can also include an educational dialogue with thepatient regarding prevention/health promotion, early detection of healthproblems, environmental issues related to the patient's health andoccupational health and safety. It is recognized that techniques mayinclude hypnosis.Payment for this service implies that it is a discrete service provided by thephysician personally. It is not a substitute for a visit involving a complete orpartial examination or assessment. This code is not to be used simplybecause an assessment and/or treatment took 15 minutes or longer, such asin the case of multiple complaints.It is payable on a third party basis when a family member is counselledbecause of the patient's serious and complex problem. It is not payable forroutine briefing or advice to relatives, which is considered part of the visitservice fee. Third party counsaelling must be provided at a booked separateappointment. Third party counselling claims are subject to a maximumof 30 minutes and should be submitted in the counselled individual's name.Diagnosis must be confirmed or the diagnostic code Z84 must be indicated.40B Counselling - first 15 minutes - includes history review, counselling, $73.60educational dialogue, intervention and record of the service provided,including time spent counselling41B -- next subsequent 15 minutes or major portion thereof $73.60May be billed by any physicianHepatitis C - Monthly stipend for overseeing treatmentMonthly stipend for managing the treatment of patients with a confirmeddiagnosis of Hepatitis C. The fees are payable for months in which treatmentis provided according to recognized protocols for Hepatitis C.Only one physician may bill this code per month. Patient contacts wouldcontinue to be paid as visit services. This fee is not eligible for premiums or surcharges.This payment stops when the active treatment protocol ends.57B Each month $100.00Palliative Hospital Care*Palliative hospital care is billable by the physician responsible for thein-hospital care of patients designated as palliative by their Regional HealthAuthority or the Saskatchewan Drug Plan. Hospital care includes all of the routineservices reequired to manage in hospital care.Additional services provided as a result of an acute episode may be payable withan explanation. An assessment or consultation may not be billed when palliativehospital care is transferred to another physician. This code cannot be billed on thesame day as regular hospital care (25B to 28B).SMA FEE GUIDE - B2 - April 1, 2012

SECTION B:GENERAL PRACTICE35B- per diem*payable on day of admissionSpinal PathwayThe Spinal Pathway code provides payment to physicians for the time they spendcompleting and recording a spinal assessment algorithm using the approvedSpinal Pathway form.Fee200B Spinal pathways $23.40# physicians that have completed the Saskatchewan Spine PathwaysCourse, "Assessment and Management of Low Back Pain" are eligibleto bill this code. This code may be billed once per acute or chronicepisode that requires completing the Spinal Pathway form and algorithm.Case ConferenceMust be a formal scheduled session. A single conference fee billed in the name ofone patient covers all the patients reviewed at that conference. Use 43B if caseconference is part of Home Care Program. A maximum of two case conferencesper patient per year is billable. The physician should keep appropriatedocumentation of time and place.42B -- per conference (not patient) $136.00first 30 minutes or part thereof43B -- per home care conference (not patient) $136.00first 30 minutes or part thereof44B -- add to 42B or 43B for each additional $61.8015 minutes or part thereofHospital Care*(Payable on day of admission)25B -- first 10 days, per day $61.8026B -- 11-20 days, per day $61.8027B -- 21-30 days, per day $61.8028B -- thereafter, per day $48.60Note: for hospital discharge by physician, see code 725A.*Payable on day of admission.25B may be billed for short term acute care patients who areadmitted to a Health Centre in the same manner as an acutecare hospital. Physicians may not use this option to covernew admissions for long term care patients.Supportive CareSupportive Care is billable by the patient's family physicianfor inpatient visits to patients formally admitted to hospitalunder a specialist where it is necessary and/or prudent forthe family physician to visit the patient to:-- promote continuity of care;-- reassure the patient and liaise with the family;-- become aware of the specialist's current and futuretreatment recommendations;-- facilitate the continuing management of the patient inthe community following discharge.Note: This service must be documented in the patient'sfile (hospital chart). This service is not payable in additionto a case conference billed for the same patient on the sameday or in conjunction with any surcharge or premium. Caseswhere the patient has spent less than 24 hours as a hospitalin-patient will only be paid if this service has not been paidin the preceeding 30 days. Services in excess of six per yearper patient are to be billed by report.SMA FEE GUIDE - B3 - April 1, 2012

SECTION B:GENERAL PRACTICEServices in excess of six per discrete hospital admissionper patient are to be billed by report which means the claimmust be accompanied by a detailed explanation of thecircumstances. Payment will be assessed on the basisof the explanation.Fee52B Initial Visit (to be billed once per $71.40admission - otherwise 53B)53B Subsequent Visits - to be billed during $71.40the patient's stay as a hospital in-patientup to a maximum of once per week(i.e. 53B is not billable within 6 days ofanother 53B)METHADONE - Monthly stipend for overseeingmethadone management60B First 3 months - per patient (lifetime $91.40maximum)61B Second 3 months - per patient (lifetime $68.60maximum)62B Thereafter - per patient $45.80-- No restarts in the payment program, i.e. if the patient leaves theprogram and then at a later date re-enters the program, his paymentwould resume at the same level as when he/she opted out.-- Only one physician will be paid the monthly stipend. Change ofphysician does not affect level of payment.-- Visits for each patient contact would be paid as at present (5B'sor 40B's) in addition to monthly stipend.-- Not eligible for premiums or surcharges.-- Entitlement to these monthly stipends is limited to physicians who:1. Have a current valid license to prescribe methadone for addiction.2. Are actively supervising the patient's continuing use of methadonewithin the provincial methadone program.Note: This payment stops when the patient stops taking methadone.Chronic Disease ManagementChronic disease management (CDM) fees are designed to encourage the useof accepted clinical care pathways to optimize the patient management. CDMfees are billable only for patients with a confirmed diagnosis of diabetes mellitus,coronary artery disease, congestive heart failure or chronic obstructive pulmonarydisease (COPD) who require ongoing longitudinal care management of thesediseases.CDM fees are billable only once per patient, every 90 days. To initiate billing ofthese codes, the physician's first CDM fee claim for the patient must includethe comment: "will be providing ongoing care to the patient". Subsequent(after 90 days) CDM fee claims must be consecutive and continuous for the samepatient/same physician or clinic and will not require a comment.A SMA approved flow sheet must be completed and care must be consistentwith approved guidelines. The approved flow sheets are available on theSMA Web site.Electronically available equivalent CDM tracking systems (e.g., ElectronicMedical Records) that interface with the Chronic Disease Management Toolkitare also eligible.The CDM fee includes a patient visit that involves at least 15 minutes ofphysician time. Visits in excess of one every 90 days, or involving less thanSMA FEE GUIDE - B4 - April 1, 2012

SECTION B:GENERAL PRACTICE15 minutes of time, should be billed using appropriate visit codes (e.g., code 5B).If the patient has more than one of these conditions, they will be dealt with atthe same visit. An approved flow sheet must be completed for each conditionand at least 5 minutes of additional time per condition will be spent.Fee64B Visit and quarterly review of chronic $68.60disease -- base feePlus add one or more of the following fees forchronic conditions assessed during the visit:65B Diabetes -- add $68.60(billable for the following diagnostic codes: 250)66B Coronary heart disease -- add $68.60(billable for the following diagnostic codes: 410-414 inclusive)67B Congestive heart failure -- add $68.60(billable for the following diagnostic codes: 425, 428, 429)68B COPD -- add $68.60(billable for the following diagnostic codes: 490, 491,492, 496, 518, 519)As an example, if a patient has coronary artery disease, the physiciancan bill fee 64B and 66B. When a physician sees a patient with morethan one chronic disease (e.g., diabetes and coronary artery disease),he/she wold bill fee 64B, 65B, and 66B for a total of $167.70.Emergency Medicine - VisitsThe following listings apply to services provided by scheduled on-siteemergency physicians providing services in hospital emergency departments.-- Surcharges are not payable with these codes.-- Other procedures and visits shall be billed using the General Practicecodes and fees as listed in the various sections.-- Physicians (e.g. on call) who choose to attend their patients in theEmergency Department but who are not the designated emergencyphysicians as defined above, shall not bill these service codes but shalluse the appropriate General Practice codes (i.e. 3B to 5B). Physiciansscheduled to work in hospital emergency departments on a call-inbasis as opposed to an on-site basis shall not bill these services butshall use the appropriate General Practice codes. These services arenot to be used for free standing treatment centres or non-hospitalemergency clinics.Visit age supplement for patients 55 years ofage and older:1. These supplements provide the physician withincreased compensation when providing aneligible visit service for a patient over 54 year of age.2. Eligible visit services include codes 9B, 11B, 15B,73B and 85B. Any other services are not eligible forthis supplement.100B for patients 55 to 64 years of age 15 percent101B for patients 65 to 74 years of age 25 percent102B for patients 75 years of age and older 35 percentNOTE: Emergency Medicine Age Supplements arebased on the value of the visit excluding other premiums and surcharges73B Complete assessment $136.00-- includes: pertinent family history, patienthistory, history of present complaint, functionalenquiry, examination of all parts and systems,diagnosis --assessment, necessary treatment,advice to the patient and record of the service providedSMA FEE GUIDE - B5 - April 1, 2012

SECTION B:GENERAL PRACTICEFee85B Partial assessment or subsequent visit $69.60-- includes: history review, history of presentingcomplaint, functional enquiry, examination ofaffected part(s) or system(s), diagnosis --assessment, necessary treatment,advice to the patient and record of the service providedPayment for patients 0-5 years of age are automatically applied. See Section A -Paediatric Visit Age Supplement for detailsSMA FEE GUIDE - B6 - April 1, 2012

SECTION C:PAEDIATRICSVisitsFee3C Complete assessment $179.00-- includes: pertinent family history, patienthistory, history of presenting complaint,functional enquiry, examination of all partsand systems, diagnosis, assessment,necessary treatment, advice to the patientand record of service provided4C Well baby care in office $73.80-- refers to the periodic office visitsduring the first year of life of ahealthy infant and includes thenecessary weights and measurements,examination and instruction to theparent regarding health care5C Partial assessment or subsequent visit $128.00-- includes: history review, history ofpresenting complaint, functionalenquiry, examination of affectedpart(s) or system(s), diagnosis,assessment, necessary treatment, adviceto the patient and record of service provided14C Complex partial assessment or subsequent visit $193.00- for eligible conditions includes: history reviewhistory of presenting complaint, functionalenquiry, examination of affected part(s) orsystems(s), diagnosis, assessment, necessarytreatment, advice to the patient and recordof service provided.For paediatric (under age 18) patient visits thatinvolve at least 15 minutes physician time and thefollowing eligible conditions:AIDS; other human immunodeficiency virus infection;Diabetes Mellitus, including complications;Coagulation defects (e.g. Haemophilia, otherfactor deficiencies); Haemorrhagic conditions (e.g.Thrombocytopenia Purpura); Multiple Sclerosis;Epilepsy; Hypertension; Congestive Heart Failure;Asthma; Pulmonary Fibrosis; InflammatoryBowel Disease; Renal Failure; Systemic LupusErythematosus, Scleroderma, Polymyositis,Dermatomyositis; Ankylosing Spondylitis, andother Seronegative Spondyloarthropathies;Chronic Hepatitis; Systemic Vasculitis; Chronic RespiratoryFailure; Child Psychosis or Autism; Behavioural disorders ofchildhood and adolescence; Specific delays in development (e.g.Dyslexia, Dyslalia, Motor Retardation); Cerebral Palsy;Chromosomal Anomalies; Congenital Heart Disease;Myelomeningocele; Foster Care Child; Technology Dependent(tube fed, trach, CPAP, oxygen dependent); Chronic LungDisease; Anerexia Nervosa; Anxiety/Mood Disorders;Panhypopituitarism; Pulmonary Fibrosis; Physical and SexualNeglect and AbuseSMA FEE GUIDE - C1 - April 1, 2012

SECTION C:PAEDIATRICSVisitsFee9C Consultation $250.00-- includes all visits necessary, historyand examination, review of laboratoryand/or other data and writtensubmission of the consultant's opinionand recommendations to the referringdoctor11C -- repeat $108.00Hospital Care(Payable on day of admission)25C -- first 10 days, per day $53.0026C -- 11-20 days, per day $48.0027C -- 21-30 days, per day $48.0028C -- thereafter, per day $48.00Note: for hospital discharge by physician,see code 725A, Section A.ProceduresAdditional payments for diagnostic serviceexcluding ECG's, 0, 10 or 42 day operativeprocedures performed on patients underone (1) year of age are automatically calcuatedand paid as explained in Section A,Paediatric Age Supplements.39C Attendance at intrauterine foetal $140.00transfusionProcedures35C Exchange transfusion -- first $362.7036C Exchange transfusion-- repeat $300.0037C Fontanelle or jugular or femoral vein $20.00puncture38C Duodenal intubation for analysis $40.70Cannulization of40C -- umbilical artery in the newborn $100.0041C -- umbilical vein in the newborn $80.00Growth hormone studies42C -- 2 hour insulin I.V. infusion $500.0043C -- subsequent arginine I.V. Infusion $150.00(includes I.V. infusion set up - bloodcollection and treatment of sideeffects/complications)50C Rashkind Septostomy $700.00SMA FEE GUIDE - C2 - April 1, 2012

SECTION C:PAEDIATRICSFeeCardiorespirogram60C -- interpretation $67.40The following codes are for use by PaediatricCardiologists for patients diagnosed withcongenital heart disease.100C Cardiac catheterization -- right heart -- toinclude catheter insertion and any or allof RA, RV, PA, and PAW pressures. Notto be billed during a routine coronaryangiogram105C Cardiac catheterization -- left -- retrogradeincludes catheter insertion and LV andAO pressures$400.00 H$400.00 H110C Oximetry during cardiac catherization $200.00115C Transluminal angioplasty -- pulmonary$1,000.00 Hvalve or artery120C Balloon dilatation of conduit or graft$1,000.00 H125C Stent placement in aorta pulmonary$1,200.00 Hartery or conduit130C Balloon dilatation of coarcation or aorta$1,000.00 H135C Atrial septal puncture by brockenbrough$600.00 Hneedle140C Pulmonary angiography $300.00145C Angiocardiography -- right and/or left side$300.00 H150C Foetal echocardiogram and foetal rhythm$306.00 H155C Pulmonary hypertension studies$800.00 HSMA FEE GUIDE - C3 - April 1, 2012

SECTION D:INTERNAL MEDICINEVisits Fee Anae3D Complete assessment $134.80-- includes: pertinent family history,patient history, history of presentingcomplaint, functional enquiry,examination of all parts and systems,diagnosis, assessment, necessary treatmentadvice to the patient and record of service provided5D Partial assessment or subsequent visit $134.00-- includes: history review, history ofpresenting complaint, functionalenquiry, examination of affectedpart(s) or system(s), diagnosis, assessment, necessarytreatment, advice to the patient and record of service provided14D Complex partial assessment or subsequent visit - for eligible $199.00conditions - includes: history review, history of presenting complaintfunctional enquiry, examination of affected part(s) or sytems(s),diagnosis, assessment, necessary treatment, advice to the patientand record of service provided.For patient visits that involve at least 15 minutes physician time andthe following eligible conditions:AIDS; other human immunodeficiency virus infection;Diabetes Mellitus, including complications;Coagulation defects (e.g. Haemophilia, otherfactor deficiencies); Haemorrhagic conditions (e.g.Thrombocytopenia Purpura); Multiple Sclerosis;Epilepsy; Hypertension with complications; Congestive Heart Failure;Coronary Artery Disease; COPD; Asthma; Pulmonary Fibrosis;Inflammatory Bowel Disease; Cirrhosis; End Stage Renal FailureSystemic Lupus Erythematosus, Scleroderma, Polymyositis,Dermatomyositis; Rheumatoid Arthritis; Ankylosing Spondylitis, andother Seronegative Spondyloarthropathies; Adult onset Still's DiseaseChronic Hepatitis; Systemic Vasculitis; Chronic RespiratoryFailure; Sleep Apnea and complicationsTechnology Dependent (tube fed, trach, CPAP, oxygen dependent);Chronic Lung Disease; Panhypopituitarism; Pulmonary Fibrosis9D Consultation - includes all visits necessary, history and examination, $283.00review of laboratory and/or other data and written submission of theconsultant's opinion and recommendations to the referring doctor.11D -- repeat $142.00Hospital Care(Payable on day of admission)25D -- first 10 days, per day $75.0026D -- 11-20 days, per day $74.0027D -- 21-30 days, per day $33.0028D -- thereafter, per day $33.00Note: for hospital discharge by physician,see code 725A, Section A.SMA FEE GUIDE - D1 - April 1, 2012

SECTION D:INTERNAL MEDICINEFee350D Follow-Up of Transplant Patient $506.00350D is payable for a visit to provide assessmentand ongoing management of a patient's conditionfollowing a heart, lung, liver or pancreas transplant.This service is payable to the physician designatedas the most responsible physician for monitoringthe post-transplant status of the patient.-- not payable in addition to other visit servicesor within 42 days of the previous 350D.-- limited to six 350D services per patient per year(beginning April 1 of each year).AnaeProceduresAdditional payments for diagnostic serviceexdluding ECG's, 0, 10 or 42 day operativeprocedures performed on patients under one (1)year of age are automatically calculated and paidas explained in Section A, Paediatric Age Supplement.Electrocardiogram or phonocardiogram30D -- tracing only $17.60 *31D -- interpretation only $22.50 *(If multiple 31Ds are done on the sameday, please use units and indicate thetime as a comment. Interpretation shouldbe billed using date of tracing)32D -- tracing and interpretation $36.40 *35D Tilt table testing for syncope - includes venous $412.00 Dand /or arterial cannulation - provocative and/orblocking drugs - physician in constantattendance39D Group exercise training sessions for cardiac $32.60 * Dor pulmonary rehabilitation patients in a hospitalapproved facility - per patientMaximum $230.00 per session(Includes supervision and all other servicesprovided during the session.The session is to be billed in the name of onepatient using the number of services (units)to represent the number of patients, up to amaximum of ten)62D Maximal or sub-maximal exercise $178.00 Dtolerance test using a bicycle ergometeror treadmill with continuous E.C.G.monitoring, full E.C.G.(s), blood pressuremonitoring -- professional supervisionand interpretation with physician inconstant attendance -- in approved facility63D -- technical (if equipment owned and staff $65.80 Demployed by physician)SMA FEE GUIDE - D2 - April 1, 2012

SECTION D:INTERNAL MEDICINE64D Cardiopulmonary Exercise Testing $326.00 * D-- technical - maximal incremental or enduranceexercise testing on a treadmill or cycleergometer with ECG monitoring, gas exchangemeasurements and pre-/post-spirometrymeasurements (if equipment owned andstaff employed by physician)Payable with code 67D and applicable visit;not payable with code 63D.67D -- professional (includes 62D, 264D, 265D x 2 $326.00 Dand 277D)Payable with aplicable visit.Stress echocardiography (applicable totreadmill, dobutamine and pacing stressechocardiography).Physician in constant attendance.65D -- technical $308.00 D66D -- professional $390.00 D141D Continuous or intermittent $83.50 * Delectrocardiogram monitoring (e.g. Holteror Cardiocassette) -- interpretation142D -- technical component and scanning (if $83.50 * Dinstruments owned by physician)144D Dipyridamole thallium test to include $203.30 Dsupervision of ETT, infusion of medicationand interpretation145D 24-hour ambulatory blood pressure $53.50 * Dmonitoring--professional component only-- one per patient per year42D Cardiac arrhythmia cardioversion $218.00 0 L44D Rogitine test $40.70 L49D Bleeding time -- Ivy (Template) test $31.00 DElectroencephalogram50D -- tracing only $45.60 D51D -- interpretation only $52.50 D53D -- insertion of sphenoidal leads -- extra $40.70 D59D Electroclinical detailed interpretation of $692.00 Da set of seizures (Telemetry)Polysomnography54D -- technical component $113.40 D55D -- professional component $221.50 D56D Electrocorticography $344.50 D57D E.E.G. monitoring during carotid $172.30 Dendarterectomy58D Sodium Amytal testing $172.30 D360D Transcranial Doppler $101.70 DSMA FEE GUIDE - D3 - April 1, 2012

SECTION D:INTERNAL MEDICINEFee AnaePulmonary264D Spirometry - FVC, FEV1, FEV1/FVE x 100, MMFR $55.00 * D(FEF25-75), V. maximum 50V. maximum 25. Best ofthree efforts according to ATS standards with orwithout flow volume curves. Not paid with PeakFlow Meters265D Repeat after bronchodilators $33.00 * DMeasurement of subdivisions of lungvolumes - TLC, FRC, VC, RV, TLV266D -- Professional component $65.20 D267D -- Technical component $51.20 DLung diffusing capacity DLco with or withoutbronchodilators at rest and after exercise each268D -- Professional component $65.20 D269D -- Technical component $48.20 DFull pulmonary function studies(including codes 264D, 265D, 266D and 268D)69D -- Professional component $167.00 D271D -- Technical component (including 267D and 269D) $97.40 D(If instruments owned and staff employed by physician)Maximum billable for any combination of abovenon-technical tests (pulmonary) is not toexceed listed fee for 69D.)272D Hyperbaric medicine - interpretation of tissue $40.00 * Doxygen concentrations/saturations to assesscandidates for hyperbaric oxygen therapy280D Overnight oximetry (not payable with $55.60 * Dpolysomnography)Airways resistance or conductance by body box400D -- Professional component $26.80 D401D -- Technical component $44.90 DMaximum expiratory and inspiratory pressures402D -- Professional component $33.60 DPulmonary compliance70D -- Professional component $66.30 DStatic pressure volume curve withesophageal balloon - pulmonary compliance71D Professional component $93.10 DSingle breath nitrogen curves75D -- Professional component $26.80 DHistamine-Methacholine test77D -- Professional component (Internist of $180.00 DPediatrician ONLY)SMA FEE GUIDE - D4 - April 1, 2012

SECTION D:INTERNAL MEDICINEFee Anae276D -- Technical component $44.90 DPulse Oximetry with exercise277D -- Professional component $27.80 D80D Transtracheal aspiration $72.80 * DG.I. Tract90D Jejunal biopsy -- trans oral $146.00 DOesophageal perfusion test92D -- interpretation $93.80 DOesophageal motility study93D -- interpretation only $97.40 DOesophageal motility study94D -- physician in continuous attendance $143.00 Dincluding interpretationExtended pH studies with or withoutprovocative drug testing95D -- physician in attendance - includes $150.00 Dinsertion and removal of probes andinterpretation96D -- interpretation only $77.20 D215D Tensilon test $40.70 * DEvoked response105D Visual evoked response interpretation $24.20 * D106D Auditory evoked response interpretation $38.50 * D107D Somato-sensory evoked response $38.50 * DinterpretationPeritoneal dialysis121D Peritoneal dialysis -- each 24 hour $66.80 0period131D Supervision of dialysis at home, per $96.60 0week132D Any subsequent dialysis in the centre -- $71.60 0eachSlide Examination300D Examination of slide for diagnosis of malaria $34.20 * D(for physicians with appropriate trainingonly)320D Nephrologist microscopic examination $34.60 Dof uring sample in officeHaematology Supervision (Haematologist only)500D Management of Acute Leukemia -per month $280.00a maximum of six months501D Management of Acute Lymphoma while $139.00patient is receiving intraveneouschemotherapy (per month)Haemodialysis122D -- initial $604.00 0123D -- second to fifth -- each $342.00 0SMA FEE GUIDE - D5 - April 1, 2012

SECTION D:INTERNAL MEDICINEFee Anae124D -- sixth and subsequent -- each $96.60 0(shunt established)128D Dialysis and training in dialysis centre -- $198.00 0each129D Any subsequent dialysis in the centre -- $83.50 0each130D Supervision of dialysis at home, per $81.30week135D Continuous Renal Replacement $876.00 0Therapy (CRRT) - initial136D Continuous Renal Replacement $330.00 0Therapy (CRRT) - subsequent - greaterthan 7 days by reportPhysician attendance at cell separationsessions150D -- initial session $470.00 0151D -- subsequent sessions $352.00 0Therapeutic plasmapheresis (done bycell separator)155D -- first $308.00 0156D -- second to fifth $206.00 0157D -- subsequent $146.00 0250D Plethysmography for penile blood flow $59.90 D251D Tumescence monitoring of penis $59.90 D270D Impedance plethysmography for deep vein $23.50 * Dthrombosis -- professional component onlyEndocrine Testing200D Cortrosyn stimulation $83.40 D201D Calcium pentagastrin stimulation $88.40 D202D T.R.H. stimulation $124.00 D203D Glucagon test $252.00 D204D L.H.R.H. stimulation $115.00 D205D Tolbutamide test $172.30 D206D Insulin tolerance test $216.00 D207D Triple bolus test $236.00 D216D Corticotropin Releasing Hormone $123.00 DDelineation Test217D Water Deprivation Test with or without $282.00 DDDAVPBotulinum Toxin TherapySee codes 190A to 198APacemaker Clinic ServicesClinic supervision, review of interrogationrecord and adjustment if necessary. IncludesECG Interpretation (not paid in addition to120L-122L, 622L)278D Patient not seen $56.00279D Patient seen $82.00 0(Visit fee payable if patient reviewed for aSMA FEE GUIDE - D6 - April 1, 2012

SECTION D:INTERNAL MEDICINEcondition unrelated to pacemaker function)POLYSOMNOGRAPHYDiagnostic Polysomnography is an insured service when providedat a provincially designated sleep laboratory and is a supervisedovernight sleep study with continuous monitoring of sleep (EEG,EOG, EMG), oxygen saturation, ECG, airflow and respiratoryeffort.Therapeutic Polysomnography is a supervised overnight sleepstudy performed in a provincially designated sleep laboratorywith continuous monitoring of sleep (EEG, EOG, EMG), oxygensaturation, ECG, airflow and respiratory effort during whichspecific therapy for sleep disordered breathing is administered(this may include CPAP/Bi-PAP or mandibular advancementdevice) and the effect monitored.Split night diagnostic and therapeutic polysomnographyprovided as a one-night study should be billed as 281D and 282D.Repeat Diagnostic Therapeutic polysomnography within 42 daysmust be accompanied by an explanation.FeeAnae281D Diagnostic (includes visit) $552.00 D282D Therapeutic (includes visit) $274.00 D283D Multiple Sleep Latency Testing $274.00 D(includes visit)284D Portable sleep study $103.00 D285D Actigraphy $110.00 DAuto-CPAP Titration290D -- professional $173.00 D291D -- technical $31.40 DCodes 281D to 291D limited to physicianswith Regional Health Authority sleep labprivileges.SMA FEE GUIDE - D7 - April 1, 2012

SECTION E:PSYCHIATRYVisitsFee5E Initial assessment $286.00-- of a specific condition includes:pertinent family history, patienthistory, history of presentingcomplaint, functional enquiry,examination of affected part(s) orsystem(s), diagnosis, assessment, necessarytreatment, advice to the patient and record ofservice provided7E Follow-up assessment $100.00-- includes: history review, functionalenquiry, examination, reassessment,necessary treatment andadvice to the patient and record of service providedConsultation-- includes all visits necessary, historyand examination, review of laboratoryand/or other data and writtensubmission of the consultant'sopinion and recommendationsto the referring doctor9E -- adult $410.0010E -- child $450.0011E -- repeat $200.00Hospital Care(Payable on day of admission)25E -- first 10 days, per day $65.60 *26E -- 11-20 days, per day $65.60 *27E -- 21-30 days, per day $50.40 *28E -- thereafter, per day $50.40 *Note: for hospital discharge by physician,see code 725A, Section A.SMA FEE GUIDE - E1 - April 1, 2012

SECTION E:PSYCHIATRYFee62E Examination and certification of need for $227.90psychiatric examination pursuant to TheMental Health Services Act with completionof Form A63E Consultation, examination, patient history, $440.00admission to hospital and certification ofmental ill health with completion ofForm G64E Consultation, examination and certification $440.00of mental ill health with completion ofForm G - second psychiatrist66E Repeat examination and recertification of $200.00mental ill health - same psychiatrist asbilled code 63E - within 22 days withcompletion of Form G67E Repeat examination and recertification of $200.00mental ill health- same psychiatrist asbilled code 64E - within 22 days withcompletion of Form G68E Consultation, examination and a $440.00recertification of mental ill health whenprevious certifying psychiatrist isunavailable - includes completion ofForm G70E Completion of certification of mental ill health with $80.00issuance of form G or form H.1/H.3/H.473E Necessary examination and certification for $80.00E.C.T. on an involuntary patient - by thepsychiatrist providing primary care who hasbilled under code 63E with completion ofForm I74E Examination and certification for E.C.T. on $80.00an involuntary patient - by secondpsychiatrist who billed 64E or who hasprior knowledge of the case - withcompletion of Form ISMA FEE GUIDE - E2 - April 1, 2012

SECTION E:PSYCHIATRYFee75E Consultation, examination and $440.00certification for E.C.T. on an involuntarypatient who has not been seen by thepsychiatrist in the preceding 42 days-with completion of Form lPsychotherapeutic Visits -- Office, Home or Hospital31E Psychiatric social interview $96.00(A maximum of three units of 31E, per personinterviewed, is authorized for billing)Interview for a minimum of 15 minutes bya psychiatrist with a person who has closeknowledge of, or association with, a patientunder the care of or treatment by thepsychiatrist, and without the patient beingpresent, to assist in the treatment of thepatient.A person being interviewed may be a spouse oranother member of the family or for example, acommunity psychiatric nurse (psychiatric homecare nurse), a teacher, or a member of theclergy or a social worker.The benefit payment for this service is for aminimum of 15 minutes structured interview ona one to one basis between the psychiatrist andthe person being interviewed.This item is not paid for a case conference wherea psychiatrist confers, in relation to severalpatients at one time, with a physician, nurse orsome other professional person participating in theprovision of services to the patients or in thesupervision or monitoring of the patients.Service code 31E should be billed in the name of thepatient, and indicate the person interviewed.SMA FEE GUIDE - E3 - April 1, 2012

SECTION E:PSYCHIATRYCase ConferenceIs where a psychiatrist confers, in relation to several patientsat one time, with a physician, nurse or some otherprofessional person participating in the provision of servicesto the patients or in the supervision or monitoring of thepatients.Must be a formal scheduled session. A single conferencefee billed in the name of one patient covers all the patientsreviewed at the conference. A maximum of six caseconferences per patient per year is billable. The physicianshould keep appropriate documentation of time and place.Fee142E - per conference (not patient) - first 30 minutes or part thereof $140.00144E - add to 142E for each additional 15 minutes or part thereof $70.00PsychotherapyPsychotherapy is a form of treatment for mentalillness, behavioral maladaptions and/or otherproblems, in which a physician establishes aprofessional relationship with a patient for thepurposes of removing, modifying or retardingexisting symptoms or attenuating or reversingdisturbed patterns of behavior, by one or moreapproaches or methods from the generallyrecognized divisions of psychology (i.e. analytic,behavioristic, gestalt, hormic, introspective). Itis recognized that techniques may include hypnosis.Group Psychotherapy33E Group size 7 to 9 persons -- first hour, $59.20per person34E -- each subsequent 30 minutes or $29.60major part thereof, per personA maximum of 2 hours applies to a combinationof 33E and 34EFamily Psychotherapy (Billed in the nameof head of family, indicating names ofother members treated)SMA FEE GUIDE - E4 - April 1, 2012

SECTION E:PSYCHIATRYFee35E Concurrent treatment of two or more $318.00members -- first 45 minutes37E -- each subsequent 15 minutes or $106.00major part thereofIndividual Psychotherapy or Psychiatric CounsellingPayment for this service implies aplanned series of sessions of at least30 minutes duration.38E -- minimum period of 30 minutes $192.0039E -- each subsequent 15 minutes or $96.00major part thereofPsychiatric Care40E -- minimum of 15 minutes $96.0041E -- each subsequent 15 minutes or major $96.00part thereofFee AnaeElectroshock therapy -- per treatment42E -- with anaesthetist $161.00 * 0 LRepetitive Transcranial Magnetic Stimulation43E -- technical component (if the equipment is $160.00 Downed and the staff are employed by thephysician)- Professional (for patient assessment use 7E visitcode, for continuous physician bedside attendanceduring procedure use 918A)Interview with drugs45E -- First 30 minutes $99.5047E -- each subsequent 15 minutes or $47.40major part thereof to a maximum of6 unitsPsychological testing50E -- simple $79.30 * D51E -- complex $155.20 DComplex psychological testing applies to the following tests:-- Mood and Anxiety Disorder Questionnaire, Departmentof Psychiatry, University of Saskatchewan-- ADI-R Autism Diagnostic InventorySMA FEE GUIDE - E5 - April 1, 2012

SECTION E:PSYCHIATRY-- ADOS Autism Diagnostic Observation Scale-- BASC Behavioral Assessment Scale for Children-- Achenback Child Behavior Checklist (teacher's, parent's)-- Crowell Structured Assessment-- Continuous Performance Test-- Wisconsin Card Sorting Test-- Goodenough Draw a Person Test (IQ)-- PANSS etc., (for Schizophrenia)-- KiddieSADS-- Minnesota Multiphasic Personality Inventory (MMPI)-- Structured Clinical Interview for DSM IV Axis I (SCID I)-- Structured Clinical Interview for DSM IV Axis II (SCID I I)Note: Physicians wishing to add tests to the above list should wrthe SMA Tariff Committee for approval.Fee52E OPTAX assessment for Attention Deficit $204.00 DdisorderSMA FEE GUIDE - E6 - April 1, 2012

SECTION F:DERMATOLOGYVisitsFee5F Initial Assessment $103.00-- of a specific condition includes:pertinent family history, patienthistory, history of presentingcomplaint, functional enquiry,examination of affected part(s) orsystem(s), diagnosis, assessment,necessary treatment, advice to the patientand record of service provided7F Follow-up Assessment $61.60-- includes: history review, functionalenquiry, examination, reassessment,record, necessary treatment, advice to thepatient and record of service provided9F Consultation $160.00-- includes all visits necessary, historyand examination, review of laboratoryand/or other data and writtensubmission of the consultant'sopinion and recommendations to thereferring doctor11F -- repeat $86.00Hospital Care(Payable on day of admission)25F -- first 10 days, per day $52.60 *26F -- 11-20 days, per day $45.20 *27F -- 21-30 days, per day $20.60 *28F -- thereafter, per day $20.60 *Note: for hospital discharge by a physician,see code 725A, page A28SMA FEE GUIDE - F1 - April 1. 2012

SECTION F:DERMATOLOGYProcedures Fee AnaeAddditional payments for diagnostic serviceexcluding ECG's, 0, 10 or 42 day operativeprocedures performed on patients under one (1) yearof age are automatically calculated and paidas explained in Section A, Paediatric Age Supplement.30F Ultraviolet A and B light sensitivity -- $143.00 * Dtesting and interpretation33F Radiotherapy - per body area $49.60 * 034F PUVA (Psoralen ultra violet) therapy -- $93.80 * 0one treatment per alternate day35F Ultraviolet B therapy $27.80 * 0Visit service not paid same day as 34F or 35Funless an explanation is provided.38F Application of nitrogen mustard -- per $78.80 * 0treatmentSpecial mycological investigations40F -- direct examination of hair or scales $30.00 * D42F Wood's light examination $16.60 * DBiopsy of skin or mucous membrane100F -- punch or shave biopsy - 1st $50.40 * D101F -- each additional (maximum of 4) $13.60 * D102F -- marginal (incisional) biopsy of skin $76.60 * 0or mucosa -- 1st103F -- each additional (maximum of 4) $27.20 * 0Comedos, acne pustules, milia - drainageor removal (only one of the codes belowcan be claimed per case)110F -- 1-5 $22.00 * 0111F -- 6-14 $42.80 * 0112F -- 15 or more $65.60 * 0SMA FEE GUIDE - F2 - April 1. 2012

SECTION F:DERMATOLOGYFee AnaeIntralesional injections120F -- by dermojet or similar means $18.60 * 0-- by needle (only one of the codes below can bebilled per case)121F -- up to 5 injections $50.60 * 0122F -- 6 or more (maximum) $76.60 * 0Treatment of localized cutaneous malignancyby curettage and cautery;888F -- any area $176.00 * 42130F Extra coporal photophoresis $142.00 * 0131F Serum autologous skin test $71.60 * DSMA FEE GUIDE - F3 - April 1. 2012

SECTION G:MEDICAL GENETICS^VisitsFee5G Genetic Assessment $172.00-- includes the history of the presentingcondition, the genetic history of thepatient and of the family, examinationof the affected part(s) or system(s)including any special techniques,diagnosis, necessary treatment,advice to the patient and record of service provided7G Follow-up Assessment $116.00All Follow-ups if a Visit -- Not Counselling-- may include a review and update of therecorded genetic history, the necessaryexamination, review of diagnosticfindings, necessary treatment, adviceto the patient and record of service9G Consultation $328.00-- includes all visits necessary, history andexamination, review of the laboratoryand/or other data and written submissionof the consultant's opinion andrecommendations to the referring doctor11G -- repeat $161.0013G Review of Genetic Information $90.60 *-- Review of clinical information for patients seenexclusively by a genetic counsellor for themedical geneticist. Dictated letter generatedfrom the visit must indicate medical geneticistinvolvement. Patient chart must include notethat clinical information was reviewed bymedical geneticist. Not payable if patientseen by geneticist within 30 days.Hospital Care(Payable on day of admission)25G -- first 10 days, per day $61.0026G -- 11-20 days, per day $45.2027G -- 21-30 days, per day $20.6028G -- thereafter, per day $20.60Note: for hospital discharge by physicians,see code 725A, Section A.ProceduresAdditional payments for diagnostic serviceexcluding ECG's, 0, 10 or 42 day operativeprocedures performed on patients underone (1) year of age are automaticallycalculated and paid as explained incalculated and paid as explained inGenetic Interview or Counselling^Billed in the name of the patient andindicating person interviewed andrelationship to the patient31G Interview with other than the patient to $59.60complete the genetic historySMA FEE GUIDE - G1 - April 1, 2012

SECTION G:MEDICAL GENETICS^Fee AnaeCounselling -- individual or family38G -- for each complete 30 minutes $152.0039G -- each additional 15 minutes or part thereof $76.0040G Chromosome analysis $142.00 * D-- interpretation onlyDetermination of probability of43G -- zygosity in twins $66.60 D50G Genetic examination of the products of $260.00 0conception (fetus and/or placenta) followingintrauterine fetal death or pregnancytermination for mutilple congenitalanomalies -- includes visit (only payableto physicians with appropriate genetictraining)^ This section is restricted to those physicians who have been designated by theCouncil of the College of Physicians and Surgeons as eligible to receivepayment for these services.SMA FEE GUIDE - G2 - April 1, 2012

SECTION H:ANAESTHESIA1. Payment for anaesthesia is for professional services for the administrationof any type of anaesthesia, general, regional, sedation or monitoredanaesthesia care in acccordance with the Canadian Society ofAnaesthesiologist's Guidelines to the Practice of Anaesthesia. However,ring block, local infiltration and topical or spray anaesthetics will not bepaid unless they meet the full definition of anaesthetic professionalservices as noted above. Payment for anaesthesia includes same daypre-anaesthetic as well as post-anaesthetic examinations and allsupportive measures during anaesthesiabut does not include the costof drugs, materials or facilities.2. An anaesthestic payment for a beneficiary:(a) is based on the time from the start of continuous attendance by theanaesthetist until such time as the attendance by the anaesthetistto that patient is no longer required. The Anaesthetic Fee Codesimplying continuous attendance may only be billed for one patientat a time.(b) includes a procedure carried out during administration of the anaestheticor in the resuscitative period except that invasive monitoring will beapproved to the primary anaesthetist in addition to the anaestheticas follows:(i) 687H, 134A, 135A, 136A, 316A, 140A, 141A or 142A at 100 percentof the appropriate listed amount;(ii) 160L at 75 percent of the appropriate listed amount.3. When more than one procedure is performed during the same anaesthetic,the payment to the anaesthetist shall be based on the highest anaestheticcomplexity as noted in the section headed "Anaesthesia Categories bySurgical Procedure".4. Pre-anaesthetic consultation on same day of surgery is aproved for highrisk cases by report.Payment for a pre-anaesthetic consultation is intended to apply wherethe consultation is provided in potentially high risk situations to assessthe fitness of the patient for the anaesthetic/surgical procedure and toadvise on pre-anaesthetic treatment. It is expected that these consultationswill apply predominantly to risk levels IV and V and are not intended toapply to a pre-anaesthetic assessment situation.5. When a physician admits a patient to a hospital for urgent surgery on anemergency basis and later on the same day provides anaesthesia servicesfor the surgeon to whom the case has been referred, then both the visitand anaesthesia services will be paid.6. In special cases where the safety of the patient or the facilitation of theoperation requires the services of a second anaesthetist, payment to theassisting anaesthetist will be based on 100 percent of the listed rate ofpayment in the same anaesthetic category as the principle anaesthetistfor the calculated anaesthetic time according to the appropriate timeunits of 15 minutes.7. "Anaesthetic Standby" is defined as professional services provided for apatient at the request of another physician during a procedure whichnormally would not require the presence of an Anaesthetist. The needfor Anaesthetic Standby should be justified by high risk or complexityof the procedure. Anaesthetic standby services should be billed underCode 918A according to criteria provided in Section A.SMA FEE GUIDE - H1 - April 1, 2012

SECTION H:ANAESTHESIA"Standby" followed by administration of anaesthesia must be clarified,for example the commencement and termination time for each service,an explanation for the necessity for "standby" with an outline of theservices provided and the name of the physician who requested the"standby".8. If an anaesthetic is provided for both dental and other surgery, the mostfavourable single base code is paid with the remainder paid as time units.VisitsConsultation-- includes all visit necessary, history andexamination, review of laboratory and/orother data and written submission of theconsultant's opinion and recommendationsto the referring doctorFee9H -- major $216.00 *11H -- repeat $108.00 *Special call surcharges for additional patients seen(refer to Section A, Special Call Services and Surcharges).Out-of-Hours Premiums - see explanation in Section A.Anaesthetics -- any type (excluding local infiltration, ring block, topicalor spray anaesthetics)Anaesthetics -- any type (excluding localinfiltrations, ring block, topical or spray anaesthetics)Where the anaesthetic category is listed as:500H Low Complexity: (Low) Startup $52.20 *501H -- Per 15 minutes $82.00 *502H Intermediate Complexity: (Med) Startup $62.30 *503H -- Per 15 minutes $94.10 *504H High Complexity: (High) Startup $74.40 *505H -- Per 15 minutes $110.00 *506H Dental Procedures: Startup $62.30 *507H Dental Procedures: -- Per 15 minutes $94.10 *Note: All dental anesthesia for patients under age 14 is insured.Complex Anaesthesia Premiums (billed in addition to regularcodes (500H to 507H) the indicated conditions exist)580H Operative premium for complexity and risk - per 15 minutes $27.60 *- for patients up to 2 years of age, a weight of greater than the97th percentile for age according to the WHO growth charts for Canada- for patients greater than 2 and up to 16 years old, a Body Mass Index,(weight[kg]/height[m]2) greater than the 97th percentile for ageaccording to the WHO growth charts for Canada- for patients over the age of 16, a Body Mass Index,(weight[kg]/height[m]2) greater than 40- patients with a massive blood loss requiring transfusion of 35 or moreml/kg of blood products585H Operative premium for complexity and risk $55.00 *-- per 15 minutes-- Patients where there is recognition and agreementbetween the surgeon and anaesthetist that unduedelay in surgical treatment would pose asignificant risk to life or major body partSMA FEE GUIDE - H2 - April 1, 2012

SECTION H:ANAESTHESIA-- Patients with multiple trauma involving atleast 2 of the following:- Abdominal injury requiring laparotomy;- Thoracic injury requiring chest tube or thoractomy;- Head injury with GCS less than 9;- Fracture of cervical spine, pelvis, femur,proximal tibia or humerus;- Burns to more than 30 percent of the body surface.FeeCodes 580H and 585H cannot be billed together.Codes 580H and 585H are not eligible for additional premiums.Premium for Anaesthesia beginning before 5:00 p.m.and ending after 5:00 p.m.540H Bill for the number of 15 minute time units $55.00 *provided after 5:00 p.m. and indicate on commentrecord the start of the anaesthetic time (this isnot eligiblel for other premiums)Example:A procedure provided on a weekday by an anaesthetic, started at 2:00 p.m.and ended at 7:00 p.m. and involved the transfusion of 40 ml/kg of bloodproducts the codes to be billed are:- no regular time based premiums are billable. The location ofservice should 2 or 3;- 504H (normally medium but greater than 4 hours) = $58.50- 505H at 20 units X $80.20 = $1,604.00- 540H at 8 units (15 minute units after 5:00 p.m.) X $18.40 = $147.20- 580H at 20 units (all 15 minute units) X $20.00 = $400.00Total billing = $2,209.70If this procedure started at 6:00 p.m. and ended at 11:00 p.m.:- the location of service would be submitted as a "B" resultingin an amount in the total premium field for eachapplicable service line;- the 540H would not be billed, and- the 580H would be billed as shown above.If the transfusion involved only 30 ml/kg of blood productsthe 580H would not be billed for the above example.Premiums for Anaesthesia beginning beforemidnight 11:59 p.m. and ending after 12:00 p.m.545H Bill for the number of 15 minute time units $55.00 *provided after 12:01 a.m. using the date ofservice when the service was initiated, andindicate on comment record the start of theanaesthetic time (545H is not eligible for otherpremiums.) Bill the number of units aftermidnight only.Example:A procedure provided on a weekday by an anaesthetist, started at9:00 p.m. and ended at 2:00 a.m. the codes to be billed are:- evening based premiums are billable using the locationof service. (See Section A, Out-of-hours Premiums)- 504H (normally medium but greater than 4 hours) plus25% evening premium = $58.50 + $14.63- 505H at 20 units X $80.20 plus 25% evening premium = $1,604.00 + $401.00- 545H at 8 units (15 minute units after 12:00 a.m.) X $18.40 = $147.20Total billing = $1,662.50 + premiums (including 545H) paid at $562.83SMA FEE GUIDE - H3 - April 1, 2012

SECTION H:ANAESTHESIAANAESTHESIA CATEGORIES BY SURGICAL PROCEDUREGENERAL CONSIDERATIONSAnaesthesia is paid on the basis of the complexity of the surgicalprocedure and the total anaesthetic time. The following outlines theclassification of anaesthetic complexity according to the surgicalprocedure(s).Low complexity:- All percutaneous diagnostic and therapeutic proceduresnot otherwise listed.- Superficial surgery on the integumentary system, nerves,vessels, muscles, tendons and bones not otherwise listed.Medium complexity:- Anaesthesia in locations remote from the Operating Roomincluding diagnostic or invasive radiology.- Anaesthesia for cases listed as "Low complexity" donein the prone or sitting position (requires note on claim).- Debridement and grafting of burns greater than 20 percent BSA.- Low complexity cases lasting longer than 90 minutes but less than 4 hoursHigh complexity :- All multiple trauma cases lasting longer than 4 hours.- Anaesthesia for live organ donor retrieval.- All cases lasting longer than 4 hours.- All cardiac catheterizations.- All laser procedures in the airway.HEADLow Complexity:- All procedures on the external, middle or inner ear.- All procedures on the eye (including cataracts) or eyelidsnot otherwise listed.- Anaesthesia for ECT.Medium Complexity:- All procedures on the skull, mandible, maxilla, orbits and facial bones.- All procedures inside the nose or accessory sinuses.- All intraoral procedures except those listed as "High complexity".- The following eye procedures: repair of open eyes, scleral buckling,vitroretinal procedures, strabismus correction, corneal transplants,glaucoma procedures, tumors and enucleation.- All closed intracranial procedures done by needle techniques.High Complexity:- All open intracranial procedures on the brain, meninges orcerebral vessels.NECKMedium Complexity:- All procedures on the thyroid gland, parathyroids, salivaryglands, lymphatics and congenital branchial cleft defects.- All endoscopic or open procedures on the larynx or tracheanot otherwise listed.High Complexity:- All procedures on the major vessels.- Anaesthesia for cystic hygroma, laryngectomy, or radicalneck dissection.- Epiglottitis, foreign body in the airway, traumatic disruptionof the larynx.SMA FEE GUIDE - H4 - April 1, 2012

SECTION H:ANAESTHESIATHORAXLow Complexity:- Anaesthesia for pacemakers, cardioversion, indwelling central lines.- All breast surgery except those procedures listed separately.Medium Complexity:- Anaesthesia for bronchosocpy, mediastinoscopy.- All procedures on the ribs.- Anaesthesia for reduction mammoplasty or (modified) radicalmastectomy, axillary node dissection.High Complexity:- All intrathoracic procedures on the heart, lungs, lymphaticsor great vessels.- All mediastinal procedures including esophagus and thymus.SPINE AND CORDMedium Complexity:- All procedures for decompression or disc surgery.- All procedures on the neninges or spinal cord and nerves nototherwise listed.- All procedures on the vertebrae (except biopsy) not otherwiselisted.High Complexity:- All procedures for spine or spinal cord tumors.- All procedures for multilevel spine instrumentation.ABDOMENLow Complexity:- All extraperitoneal procedures on the abdominal wall orurinary tract.- All endoscopic procedures of the GI tract from esophagusto rectum.Medium Complexity:- All intra-abdominal procedures except those listed belowas "High complexity".High Complexity:- Resection of liver, pancreas, stomach, colon, kidney,adrenals or retroperitoneal tumors.- All stomach procedures for weight reduction on morbidly obesepatients.- Radical cystectomy and ileal conduit surgery Radical prostatectomy,radical hysterectomy or Caesarean hysterectomy.- All procedures on the aorta, its major intra-abdominal branchesor vena cava.- Repair of congenital gastroachisis or omphalocele.PERINEUMLow Complexity:- All perianal or anorectal procedures (perineal approach).- All endoscopic urology except those listed below as "Mediumcomplexity".- All procedures on the male external genitalia.- All procedures on the female external genitalia except thoselisted below as "Medium complexity."Medium Complexity:- Transurethral resection of prostate or bladder tumor.- Percutaneous nephrolithotripsy.SMA FEE GUIDE - H5 - April 1, 2012

SECTION H:ANAESTHESIA- Hysterosocpic endometrial ablation, vaginal hysterectomy.- Radical vulvectomy with or without node dissection.- Amputation of the penis with or without node dissection.- Vaginal fistulae repairs, vaginectomy.FeeEXTREMITY SURGERYLow Complexity:- All distal or minor proximal orthopaedic procedures, includingarthroscopy, not otherwise listed.- All surgery for vascular access.Medium Complexity:- Arthroplasty of the hip, knee or shoulder.- All open surgery on the pelvis, hip, femur or tibial plateau.- Arterial vascular surgery outside the abdomen except AV fistulas.- All limb amputation except fingers and toes.- Myocutaneous flaps.- Major tissue resections and/or regional node dissection formalignant disease.- ACL reconstruction or shoulder repair.- Major releases for clubfoot.High Complexity:- Revision of arthroplasty for hip or knee.- Free flaps or microvascular revascularization.Epidural Anaesthesia for Labour and Delivery600H Initial set-up and subsequent maintenance of $644.00 *epidural anaesthesia by intermittent top-upsor continuous infusion, including continuousattendance at bedside during labour(Premiums are determined by the time of theinitial set-up)601H Restart of 600H of a previously functioning $318.00 *epidural. Not payable for anaesthesia shiftchanges. Please provide time of initialstartup and restart. (Premiums are determinedby the time of the restart set-up)667H Attendance during delivery, (after the first $79.00 *hour covered under Code 600H) per 15 minutesor portion thereofEpidural paid at 75 percent where Delivery andEpidural (600H and 601H) are provided by thesame physician by report.Intra-operative Transoephageal Echocardiography687H Intra-operative Transoephageal $232.00 *Echocardiography(billable with other echocardiogram orSwan-Ganz by report only)PAIN MANAGEMENTAcute Pain Management190H Initiation of patient controlled analgesia $32.00 *191H Injection of intrathecal opiate for post- $32.00 *operative pain management192H Insertion or reinsertion of continuous epidural $110.00 *catheter for acute pain control includinginitial infusion of analgesic agent (for obstetrical cases see 600H)SMA FEE GUIDE - H6 - April 1, 2012

SECTION H:ANAESTHESIAFee193H Daily supervision of any acute pain control $56.00 *modality listed in this Acute Pain Managementsection starting the day after surgery(includes all patient visits and adjustments)Anae194H Insertion or reinsertion of continuous $110.00 *catheter technique local naesthetic blockage(excluding epidural) for acute pain controlincluding initial infusion of analgesicagent195H Injection of local anaesthetic to establish a $110.00 *major plexus block to assist in post-operativepain management (can not be claimed fortopical, local infiltration or peripheralnerve block)Nerve BlocksThe codes in this section are for use with conditions where painis the presenting complaint or symptom, to diagnose (confirm nervesupply, etc.) and/or treat (sclerosis, etc.).These items are not for use with regional anaesthesia prior to surgery,delivery, reduction of fractures, manipulations, etc. Regionalanaesthesia provided by the same physician providing the surgicalservices is an inclusion in that service. Nerve blocks canbe billed at 75 percent with pain clinic services, visit servicesand consultations for pain.Facet Injection94H -- single $172.00 * 095H -- each additional to a maximum of 5 $84.50 * 0Trigger Point96H -- single $84.50 * 097H -- one additional $41.50 * 0Instances where more than two injections arereqired will be reviewed at the request of thephysician, upon receipt of an explanation ofthe circumstances.Peripheral or Paravertebral Nerves98H -- single $175.00 * 099H -- each additional to a maximum of $87.00 * 0three additional units-- with sclerosing agent100H -- single nerve, add $64.00 * 0101H -- each additional nerve to a maximum $41.00 * 0of three units, add102H Sciatic or obturator nerve $230.00 * 0103H -- with sclerosing agent $300.00 * 0111H Trigeminal nerve, posterior root $384.00 * 0112H -- with sclerosing agent $600.00 * 0113H Intracranial nerve $200.00 * 0114H -- with sclerosing agent $346.00 * 0120H Somatic plexus, (e.g. Brachial) $256.00 * 0121H -- with sclerosing agent $300.00 * 0130H Stellate ganglion $256.00 * 0131H Stellage ganglion -- with sclerosing agent $300.00 * 0SMA FEE GUIDE - H7 - April 1, 2012

SECTION H:ANAESTHESIAFee Anae132H Lumbar sympathetic chain $256.00 * 0133H -- with sclerosing agent $300.00 * 0134H Other ganglion/plexus (e.g. Caelic) $520.00 * 0135H -- with sclerosing agent $600.00 * 0Epidural140H -- lumbar or caudal $384.00 * 0141H -- with sclerosing agent $450.00 * 0142H -- cervical or thoracic $384.00 * 0143H -- with sclerosing agent $450.00 * 0144H Epidural blood patch $384.00 * 0145H Differential diagnostic subarachnoid block $450.00 * 0Subarachnoid150H -- lumbar $384.00 * 0151H -- with sclerosing agent $600.00 * 0152H -- thoracic $300.00 * 0153H -- with sclerosing agent $600.00 * 0158H Injection of piriformis muscle $164.00 * 0160H Diagnostic sympathetic thermal response $50.00 * 0monitoring (via thermo-couple -- paid inaddition to 130H, 132H 133H161H X-ray control in connection with service, codes 94H to 153H, add $116.00 * 0Note: x-ray charges extra220H Therapeutic intravenous regional $300.00 * 0-- anaesthesiaAnaesthesiaPain ClinicThe following codes apply to services to patients with severe or chronicpain, which have been unresponsive to previous therapy; and who havebeen referred by a physician to a designated pain clinic centre recognizedby Saskatchewan Health. The Initial Complete Assessment can bebilled on an in-patient if the patient is admitted to the hospital as analternative to the out-patient pain clinic in order to facilitate the work-up.9H should be used for consultation on hospitalized patients with acute orchronic pain not specifically admitted for pain clinic work-up. Entitlementto these benefits is limited to a recognized specialist in anaesthesia orother physician with approved training. For other physicians involved inthe pain control process the appropriate assessment within their ownspecialty section applies.201H Initial Complete Assessment $400.00 *-- includes pertinent family and patient history,pain history including review of previoustherapies, functional enquiry, examinationof all parts and systems necessary todiagnose and initiate treatment--completerecord with written report to referringphysician, and advice to patient203H Subsequent assessment -- in-patient or $200.00 *out-patient-- includes review of problems, reassessmentof pain control, review of history and physicalexamination as necessary to maintainongoing treatment, and advice to patientSMA FEE GUIDE - H8 - April 1, 2012

SECTION H:ANAESTHESIAFee205H Minor routine follow-up assessment of patient $150.00 *hospitalized under pain clinic criteria-- routine follow-up of pain treatment, withevaluation, and necessary changes toongoing careIntensive CarePREAMBLEThe intensive care payment section is intended to be used by physiciansproviding direct bedside care to critically ill and potentially unstable patientswho are in need of intensive treatment. For less intensive situations, such aswhere patients are admitted to the CCU or ICU for monitoring it may beappropriate to use a visit fee (see below) along with codes 335H-339H.This section will ordinarly be billed under the physician-in-charge of the patientfor that day. Ventilatory support care is to be billed by the physician providingventilator care, which could be the physician-in-charge or another physician.For patients who are readmitted to the unit greater than 72 hours after discharge,the first day rate will apply.If another member of the team (physicians who share call for the ICU) sees thepatient in an emergency situation with the physician-in-charge being unavailable,the use of a consultation fee may be permitted if accompanied by an informativecomment or written explanation (by report).Other physicians, such as surgeons, nephrologists and neurologists, concurrentlyinvolved in the patient's care can bill for consultations and/or visits. Physicianscalled in for a specific procedure (e.g. to insert a difficult arterial line) should bebill a procedure fee only. For patients transferred from one hospital to another,the original ICU team can bill for the transfer day, while the receiving team canbill for a day 1 onwards (e.g. ICU A will bill for April 1 to 4 (last day) and thereceiving ICU B will bill for April 4 and onward).Premiums and surcharges are not payable with codes in this section, withthe exception of the 335H-339H series of codes (less intensive patientfees).Billing for Consultations/Procedures Concurrent with the BillingVisits including consultations and some procedures are included in intensivecare services when provided in the ICU/CCU units on the same day by thesame physician, clinic or specialty.INTENSIVE CARE PER DIEM LISTINGS1. The fees under physician-in-charge (normally the mostresponsible physician) apply per patient treated, i.e. whilethe physician-in-charge may change during the course oftreatment, the daily fee formula as set out should be billedby the physicians involved as if there was only onephysician-in-charge during the treatment program; in thissense, the daily fees can be construed as team fees.2. When billing Intensive (Critical, Ventilatory or Comprehensive)Care fees, no other Intensive Care codes may be billed by thesame physician(s) or same clinic or specialty. If a physicianprovides both critical and ventilatory care it should be billed asthe comprehensive care codes. In either event the total feescannot exceed the comprehensive fees.3. Other physicians apart from those providing Critical Care orComprehensive Care may claim the appropriate consultation, visitand procedure fees not listed in the fee schedule for Intensive Carewith a meaningful explanation.SMA FEE GUIDE - H9 - April 1, 2012

SECTION H:ANAESTHESIA4. If Ventilatory Support only is provided, for example, by theanaesthetist(s), claims should then be made under VentilatorySupport. Comprehensive Care per diem fees do not apply.5. If the patient has been discharged from the Unit for more than72 hours and is re-admitted to the Unit, the first day rate appliesagain on the day of re-admission. The discharge and re-admissiontimes must accompany the billing submission.6. The appropriate visit and procedural codes apply after stoppingCritical Care, Ventilatory Support or Comprehensive Care.7. The Intensive Care per diem fees should not be claimed for stabilizedpatients and those patients who are in an intensive care unit for thepurposes of monitoring. The appropriate consultation, assessmentand procedural codes may apply (see preamble).8. Intensive Care per diem fees do not include:- Echocardiography (321A, 521A, 531A, 323A, 523A, 533A, 324A,534A, 557A, 150C);- E.C.G. provided by non-team (ICU) physicians (31D);- Closed Chest Drainage (95L);- Cardiac Pacemaker Insertion (121L);- Balloon Pump Insertion (132L);- Insertion of central venous catheter 134A-135A;- Intra-operative Transoephageal Echocardiography (687H);- Swan-Ganz Catheterization (316A);- Cardiac Catheterization and Angiography (300A, 303A, 328A, 329A,335A, 443A, 445A, 447A, 536A, 545A, 548A, 648A, 100C, 105C, 145C);- Cardioversion (42D);- Continuous Renal Replacement Therapy (CRRT) (135D, 136D);- Transcranial Doppler (360D);- Exercise Stress Test (62D);- Stress Echo (66D);- Peritoneal Dialysis (121D, 667L, 669L, 670L);- Haemodialysis (122D-124D, 660L, 661L);- Epidural Anaesthesia and Nerve Blocks (94H-161H, 192H-195H, 220H);- Percutaneous Endoscopic Gastrostomy (Peg) (443L, 444L, 447L)- Sigmoidoscopy (449L, 450L);- Colonoscopy (448L);- Oesophagogastroscopy (402L - 412L);- Bronchoscopy (520L);- ERCP (500L); or- Intubation for Laryngeal Obstruction (171T)- Tracheostomy (177T)- Certification of brain death and organ donor assessment (140Q, 150Q)Critical care codes (400H to 424H) can be billed at the same timeas the procedures listed above with no reduction to the daily feesor units.INTENSIVE CARECritical care - (Intensive Care Area) - includes provision of all aspects of careof a critically ill patient in an intensive Critical Care Area excluding ventilatorysupport and including initial consultation and assessment, emergencyresuscitation, intravenous lines, endotracheal intubation, cutdowns,intraosseous infusion, pressure infusion sets and pharmacological agents,insertion of arterial, urinary catheters and nasograstric tubes, securing andinterpretation of laboratory tests, oximetry, transcutaneous blood gases,and intracranial pressure monitoring interpretation and assessment whenSMA FEE GUIDE - H10 - April 1, 2012

SECTION H:ANAESTHESIAindicated (excluding insertion of I.C.P. measuring device). These fees arenot billable for services rendered to patients admitted for E.C.G.monitoring or observation alone.FeePhysician-in-Charge is the physician(s) daily providing the above.400H 1st day $664.00 *401H 2nd day $371.00 *402H 3rd to 7th days (inclusive) per diem $334.00 *403H 8th to 30th days (inclusive) per diem $168.00 *404H thereafter, per diem $61.80 *Ventilatory Support (Intensive Area) - includes provision of ventilatorycare including initial consultation and assessment of the patient, intravenouslines, endotracheal intubation with positive pressure ventilation includinginsertion of arterial lines, tracheal toilet, use of artificial ventilator and allnecessary measures for its supervision, obtaining and interpretation ofblood gases, oximetry, transcutaneous blood gases and assessment.Physician-in-Charge is the physician(s) daily providing the above.410H 1st day $580.00 *411H 2nd day $290.00 *412H 3rd to 7th day (inclusive) per diem $292.00 *413H 8th to 30th day (inclusive) per diem $194.00 *414H thereafter, per diem $74.80 *Comprehensive Care (Intensive Care Area) - these fees apply to IntensiveCare physicians who provide complete care (both critical Care and Ventilatorysupport as defined above) to Intensive Care Area patients. These feesinclude the initial consultation and assessment and subsequent examinationsof the patient, endotracheal intubation, tracheal toilet, artificial ventilationand necessary measures for respiratory support, emergency resuscitation,insertion of intravenous lines, cutdowns, intraosseous infusion, arterialand/or venous catheters, pressure infusion sets and pharmacologicalagents, defibrillation, cardioversion and usual resuscitative measures,insertion of urinary catheters and nasogastric tubes, securing andinterpretation of blood gases and laboratory tests, oximetry, transcutaneousblood gases, intracranial pressure monitoring interpretation and assessmentwhen indicated (excluding insertion of I.C.P. measuring device).Intensive Care fees are not billable for services rendered to patientsadmitted for E.C.G. monitoring or observation alone. If the patient has beenreassigned from critical care to comprehensive care, the day of the transfershall be deemed for payment purposes to be the second day of comprehensivecare and may be billed with a meaningful explanation (e.g. A patient was incritical care from April 1 to 4 and then transferred to comprehensive care onApril 4 to 6. The billing would be 400H, 401H, 402H, 421H and 422H.Physician-in-Charge is the physician(s) daily providing the above.420H 1st day $1,100.00 *421H 2nd day $496.00 *422H 3rd to 7th days (inclusive) per diem $496.00 *423H 8th to 30th day (inclusive) per diem $248.00 *424H thereafter per diem $128.00 *SMA FEE GUIDE - H11 - April 1, 2012

SECTION H:ANAESTHESIALess Intensive Patients (such as Monitoring)Payment of these fees is for care of less intensive patients provided ineither an Intensive Care or Coronary Care Unit. Code 918A (continuouspersonal attendance) may apply for services provided in other locations.FeePayment is intended for the time that a physician spends with the patient.The times of each visit must be indicated on the claim by the physicianproviding the service.Payment for concurrent care is only acceptable if submitted with anexplanation satisfactory to Saskatchewan Health.The procedures excluded from intensive care per diem listings on pages H.16 andH.17 are also excluded from this section (e.g. echocardiography, dialysis, etc.).However the number of time units must be reduced accordingly for335H to 339H.As well, codes in this section are eligible for after-hours premiums andfirst patient surcharges (see page A36).It may be appropriate to bill for a consultation/visit with these fee codes(see preamble page H.15). In some circumstances accurate times andmeaningful explanations must be included with submission.Per 1/4 hour (please indicate the number of1/4 hours as units) $58.00 *335H 1st day - max per day $348.00 *336H 2nd day - max per day $290.00 *337H 3rd to 7th days - max per day $174.00 *338H 8th to 30th day - max per day $116.00 *339H thereafter, per diem - max per day $76.70 *Where a patient is transferred from critical care to less intensive care the careis considered a continuation of the same hospitalization and care is based onthe number of days since the initial hospitalization or the first day of intensivecare (e.g. If a patient was in critical care from April 1 to 4 and moved to lessintensive care on April 4 to 6, the codes billed would be 400H, 401H, 402Hand 337H etc.).ECG interpretations may be billed in addition to 335H to 339H.SMA FEE GUIDE - H12 - April 1, 2012

SECTION I:CARDIOLOGYVisitsFee3I Complete assessment $146.00-- includes: pertinent family history,patient history, history of presentingcomplaint, functional enquiry,examination of all parts and systems,diagnosis, assessment, necessarytreatment, advice to the patient andrecord of service provided5I Partial assessment or subsequent visit $141.00-- includes: history review, history ofpresenting complaint, functionalenquiry, examination of affectedpart(s) or system(s), diagnosis,assessment, necessary treatment,advice to the patient and record of service provided9I Consultation $284.00-- includes all visits necessary, historyand examination, review of laboratoryand/or other data and writtensubmission of the consultant'sopinion and recommendations to thereferring doctor11I -- repeat $141.0013I Interpretation of telephone rhythm strips and/or ECG's by $70.00Cardiologist with prompt response and advice to thereferring physician on immediate case management (notto be used for routine test interpretation) per patientHospital Care(Payable on day of admission)25I -- first 10 days, per day $68.60 *26I -- 11-20 days, per day $47.00 *27I -- 21-30 days, per day $32.00 *28I -- thereafter, per day $21.00 *Note: for hospital discharge by physician,see code 725A, Section A.SMA FEE GUIDE - I1 - April 1, 2012

SECTION I:CARDIOLOGYFee Anae105I Full electrophysiology study - atrial and ventricular $2,300.00 Dprogrammed electrical stimulation110I Partial electrophysiological study - atrial or ventricular $950.00 Dprogrammed electrical stimulation115I Electrophysiological study using previously inserted electrode $550.00 D120I Esophageal electrophysiological study $400.00 D125I Intra-operative electrophysiological study $1,060.00130I Electrophysiological study/ablation - team fee - second 50% of 0physician must be certified electrophysiologist - maximum Electrophysiologistfee of $1,000.00fee135I Cardiac electrophsiologic drug infusion study - per $70.00 D15 minutes or major portion thereof200I Catheter ablation of supraventricular tachycardia (SVT) $522.00 0in addition to an electrophysiology study - add205I Catheter ablation of ventricular tachycardia (VT) in $850.00 0addition to an electrophysiology study - add210I Repeat catheter ablation at a second site during the $270.00 0same electrophysiology study300I ICD clinic services - patient seen - clinical supervision, $130.00 0review of interrogation record and necessary adjustment -includes ECG interpretation305I Implantable cardioverter defibrillator (ICD) - $790.00 0 Hdefibrillation testing (DFT)SMA FEE GUIDE - I2 - April 1, 2012

SECTION K:NEUROSURGERYVisitsFee5K Initial Assessment $101.00-- of a specific condition includes:pertinent family history, patienthistory, history of presentingcomplaint, functional enquiry,examination of affected part(s) orsystem(s), diagnosis, assessment,necessary treatment, advice to the patient andrecord of service provided7K Follow-up assessment $59.80-- includes: history review, functionalenquiry, examination, reassessment,necessary treatment, advice to the patient andrecord of service provided8K Consultation -- spinal, complex $320.00-- at least 30 minutes documented durationincluding history, physical, review of imagingand recommendations to referring physician-- includes traumatic, tumor, infection,degenerative-- can be billed by all neurosurgeon specialists-- can also be billed by physicians who perform spinalinstrumentation and fusion procedures10K Consultation -- spinal, routine $210.00-- less than 30 minutes documented durationincluding history, physical, review of imagingand recommendations to referring physician-- can be used for spine referral-- can be billed by all neurosurgeons andorthopaedic surgeons9K Consultation $210.00-- includes all visits necessary, historyand examination, review of all laboratoryand/or other data and writtensubmission of the consultant'sopinion and recommendations to thereferring doctor11K -- repeat $104.0014K Follow-up visit, spinal, complex $120.00-- billable for those patients previously billedas initial spine consult, complex-- billable by physicians who have written priorapproval by the SMA Tariff Committee-- can be billed by all neurosurgeon specialists-- can also be billed by physicians who perform spinalinstrumentation and fusion procedures15K Follow-up visit, spinal, routine $91.60-- can be billed by all neurosurgeons andorthopaedic surgeonsSMA FEE GUIDE - K1 - April 1, 2012

SECTION K:NEUROSURGERYFeeHospital Care(Payable on day of admission)25K -- first 10 days, per day $55.20 *26K -- 11-20 days, per day $53.00 *27K -- 21-30 days, per day $23.00 *28K -- thereafter, per day $22.60 *Note: for hospital discharge by physician,see code 725A, Section AAnaeProceduresAdditional payments for diagnostic service excluding ECG's,0, 10 or 42 day operative procedures performed on patientsunder one (1) year of age are automatically calculated andpaid as explained in Section A, Paediatric Age Supplement30K Cisternal puncture $77.00 * D L31K Subdural taps through fontanelle: $77.00 * D Linitial or repeat32K Ventricular puncture through previous $129.50 D Mburr or fontanelle33K Burr hole ventriculography $369.20 0 M35K Implantation of an intracranial monitor for $472.00 0 Lmeasuring intracranial pressure36K Double blind morphine pain study $227.90 DIntracranial Procedures -- Non-traumatic50K Operative management of brain abscess $2,300.50 42 H51K Sub-occipital craniectomy for tractotomy $2,473.80 42 Hor cranial nerve section52K Fifth root section $1,391.00 42 H253K Micro surgical decompression of $2,238.00 42 Mcranial nerve66K Percutaneous thermocoagulation (Rhizotomy) $1,421.00 42 Lof trigeminal nerve or ganglionCraniotomy and orbital decompression55K -- unilateral $2,300.50 42 H56K -- bilateral $2,731.70 42 H57K Cerebellar or cerebral tumor -- $4,142.00 42 Hexcision58K Cerebellar or cerebral arteriovenous $3,682.00 42 Hmalformation or aneurysm -- excision orobliteration59K Stereotactic procedures - framed or frameless to $2,675.00 42 Hobtain deep tumor biopsy, localization and guidanceduring crainiotomy for tumor excision60K Cortical excision for epilepsy, $2,675.00 42 Hhypophysectomy or excision of choroidplexus61K Intra-operative electrophysiological $642.00 42monitoring and/or stimulation-- add to any intracranial procedureExcision of62K -- osteomyelitis of skull $1,489.40 42 M63K -- skull tumor $1,489.40 42 M64K -- skull tumor with immediate $1,489.40 42 Mcranioplasty65K Extra-axial brain tumor (microdissection, $5,400.00 42 HCO2 laser, ultrasonic aspirator)80K Ventriculocisternostomy $1,599.70 42 M81K Repair of encephalocele $1,759.10 42 H82K Shunts for hydrocephalus -- any type $2,042.00 42 M83K -- revision during the same hospital $1,412.40 42 MSMA FEE GUIDE - K2 - April 1, 2012

SECTION K:NEUROSURGERYadmission as original procedureFeeAnae84K -- revision - independent procedure $1,883.20 42 Mupper end85K -- lower end $1,002.60 42 M86K Removal of ventriculo peritoneal shunt $424.80 42 Lwithout simultaneous revisionCraniectomy for craniostenosis90K -- single suture $2,140.00 42 M91K -- multiple sutures $2,140.00 42 M92K Lateral canthal advancement -- unilateral $2,041.60 42 M93K -- bilateral $2,595.80 42 MBurr holes100K -- exploratory with or without biopsy $524.30 42 M101K -- with external ventricular drainage $806.80 42 M102K -- with C. T. guided biopsy $769.30 42 M103K Sub-temporal decompression $958.70 42 M105K Carotid ligation with Selverston clamp $1,391.00 42 H106K Extracranial -- intracranial bypass $3,383.30 42 HProcedures for Traumatic Intracranial LesionsEvacuation of haematoma113K -- via burr holes $1,838.00 42 M114K -- via craniotomy $2,530.00 42 H116K Elevation of simple depressed skull $1,380.00 42 Mfracture117K Compound depressed skull fracture with $2,996.00 42 Hdebridement of brain and repair of dura118K Compound depressed fracture with sinus $1,637.10 42 Minvolvement or reconstruction of the orbit119K Cranioplasty for skull defect $1,632.00 42 M121K Craniotomy for cerebrospinal fluid $1,988.00 42 Hrhinorrhea122K Intracranial duraplasty -- for a deficiency $338.10 42greater than 2 cm. diameter -- add tointracranial procedurePeripheral Nerve Lesions156K Biopsy of sural nerve $400.00 D L157K Removal of tumor -- major peripheral $1,000.00 42 Lnerve (e.g. median or ulna)Decompression of entrapment syndrome158K -- median nerve $642.00 42 L159K -- others $1,000.00 42 L160K Section or crushing of nerve $282.50 42 L161K Neuroma excision $700.00 42 L162K Exploration of peripheral nerve injury, or $864.00 42 Lneurolysis163K Nerve suture (other than digital) $1,200.00 42 L164K Nerve suture with special techniques to $1,400.00 42 Lovercome gap165K Digital nerve suture $800.00 42 L166K Exploration of brachial or lumbar plexus $1,070.00 42 Lwith or without suture167K Nerve anastomosis for intracranial nerve $1,070.00 42 Linjury368K Secondary or delayed nerve repair -- one $300.00 42 Lmonth post injury, add468K Fascicular instead of epineural nerve $535.00 42 Mrepair, addSMA FEE GUIDE - K3 - April 1, 2012

SECTION K:NEUROSURGERYFeeAnaeNerve grafting procedures168K -- single cable $978.00 42 L268K -- multiple cables $1,421.00 42 L169K Transposition of ulnar nerve $904.00 42 L170K Extracranial anastomosis for facial nerve $1,020.80 42 Llesion -- hypoglossal accessory, etc.171K Radiofrequency spinal rhizotomy $406.60 0 LFacial nerve - microsurgical graft172K -- neurosurgeon $1,020.80 42 L173K -- general surgeon $602.00 42 L174K Selective dorsal rhizotomy for spasticity $2,369.00 42 M175K DREZ procedure for intractable pain $1,691.70 42 MVegetative Nervous SystemCervical sympathectomy180K -- unilateral $1,002.60 42 M181K -- bilateral $1,174.90 42 MCervico-thoracic sympathectomy182K -- unilateral $886.00 42 H183K -- bilateral $1,065.70 42 HLumbar sympathectomy184K -- unilateral $1,020.80 42 M185K -- bilateral $1,463.80 42 M188K Presacral neurectomy $603.50 42 M189K Phrenicotomy $362.70 42 MExposures for Neurosurgery210K Transabdominal exposure of lumbar and $902.00 42 Mlower thoracic spine for neurosurgicalprocedure211K Transthoracic exposure of lower cervical $850.00 42 Mor thoracic spine for neurosurgicalprocedure212K Transphenoidal exposure of pituitary $1,800.00 42 Mfor hypophysectomyNote: Standby time is billable as 50J for theperiod of time between the completion ofopening and the start of the closure.Example: if procedure is 3.5 hours inentirety and- opening and closure combined takes1 hour- standby is then 2.5 hoursThe total billing would be the appropriateK code (210K, 211K or 214K) and ten 15minute units of 50J.Codes 210K to 212K are exempt from themultiple surgery rules.Deep Brain Electrode for Movement Disorders235K Installation of deep brain electrode $3,000.00 42 H236K - add - Micro-electrode recording and stimulation $1,000.00 42 H237K - add - Internalization of deep brain electrode using single $500.00 42 Hchannel IPGSMA FEE GUIDE - K4 - April 1, 2012

SECTION K:NEUROSURGERYFeeAnae238K - add - Internalization of deep brain implant using dual $800.00 42 Hchannel IPG or pulse generatorNeuromodulation Clinic ServicesClinic supervision, patient monitoring andadjustment of stimulation paramaters, drugdose and/or drug mix, includes advice tothe patient, either directly or indirectlythrough the neuromodulation nurse.278K Patient -- not seen $57.60279K Patient -- seen $85.20 0(Visit fee payable if patient reviewed for acondition unrelated to neuromodulationdevice function).SPINE SURGERYAnterior DecompressionCervical500K Odontoidectomy $3,300.00 42 H501K -- exposure by separate surgeon $2,546.00 42 H502K -- exposure by preimary surgeon -- add $770.00 42503K Discectomy -- 1 level $2,136.00 42 M504K -- each additiona level -- add $594.00 42505K Vertebrectomy -- includes adjacent discs $3,338.00 42 H506K -- each additiona level -- add $576.00 42(Maximum of 3 additional levels)507K Artificial discs -- includes discectomy and fusion $4,000.00 42 H508K -- each additiona level -- add $3,000.00 42(Maximum of 1 additional level)Fee codes 507K and 508K are not billable withany other cervical decompression, fusion orinstrumentation code.Thoracic514K Discectomy $2,000.00 42 M714K - each additional level - add $566.00 42 M515K Vertebrectomy -- includes adjacent discs $3,360.00 42 H516K -- each additional level -- add $500.00 42(Maximum of 3 additional levels)517K Exposure by primary surgeon $880.00 42 MLumba523K Discectomy $2,034.00 42 M723K - each additional level - add $566.00 42 M524K Vertebrectomy -- includes adjacent discs $3,258.00 42 H525K -- each additional level -- add $500.00 42(Maximum of 2 additional levels)526K Artificial disc -- includes discectomy and fusion $4,000.00 42 H527K -- each additional level -- add $3,000.00 42(Maximum 1 additional level)528K Exposure by primary surgeon $600.00 42 MPosterior DecompressionCervical and ThoracicLaminectomy, Laminotomy, Foraminotomy534K -- unilateral $1,730.00 42 M535K -- bilateral $2,036.00 42 M536K -- each additional level -- add $450.00 42(Maximum 4 additional levels)537K -- Discectomy -- add $610.00 42538K -- Foramen magnum -- add $1,018.00 42539K Laminoplasty - includes strut and fixation $2,646.00 42 MSMA FEE GUIDE - K5 - April 1, 2012

SECTION K:NEUROSURGERY540K -- each additional level -- add $610.00 42 M(Maximum 5 additional levels)FeeAnaeLumbarLaminectomy, Laminotomy, Foraminotomy546K -- unilateral $1,840.00 42 M547K -- bilateral $2,300.00 42 M548K -- each additional level -- add $518.00 42(Maximum 5 additional levels)549K -- descectomy -- add $576.00 42Pedicale subtraction osteotomy550K -- above lumbar 2 $1,600.00 42 M551K -- below or at lumbar 2 $1,200.00 42 MFor the purpose of fusion and instrumentation, alevel is defined as two vertebral bodies with anintervening disc space.Fusion (degenerative, tumour, trauma, orinfective conditions)AnteriorCervical, Thoracic, Lumbar557K -- first level fused $1,036.00 42 M558K -- each additional level -- add $346.00 42 M(Maximum 4 additional levels)PosteriorCervical, Thoracic, Lumbar564K -- first level fused $920.00 42 M565K -- each additional level -- add $204.00 42 M(Maximum 5 additional levels)566K Autologous bone graft harvest from distant site $700.00 42 M567K Preparation of allograft $500.00 42 M(Not including premade grafts)InstrumentationAnterior573K Cervical $920.00 42 M574K -- each additional level -- add $230.00 42 M(Maximum 3 additional levels)575K Odontoid screw $2,984.00 42 HMay claim fracture decompression in addition,not fusion.576K Thoracic & Lumbar $1,200.00 42 H577K -- each additional level -- add $200.00 42 M(Maximum 3 additional levels)Posaterior583K Cervical 1-2 screw fixation $2,530.00 42 M584K -- if occiput included -- add $1,150.00 42585K -- each additional level below Cervical 2 -- add $460.00 42(Maximum of 8 additional levels)586K Cervical 1-2 wiring $1,130.00 42 M587K -- if occiput included -- add $1,000.00 42588K -- each additional level below C2 -- add $400.00 42-- maximum of 8589K -- hook or wire construct added to another $500.00 42procedureBelow C2590K 1st level $1,840.00 42 M591K -- each additional level -- add -- maximum of 8 $400.00 42592K -- each additional level beyond 8 $200.00 42(Maximum of 5 additional levels)SMA FEE GUIDE - K6 - April 1, 2012

SECTION K:NEUROSURGERY593K Iliac screws -- add $500.00 42594K -- crossing cervicothoracic junction -- add $400.00 42FeeAnaeRemoval600K Anterior or posterior -- per 15 minutes of $184.00 42 Msurgical timeMay be billed with other proceduresFractures606K Decompression and/or reduction of fracture $1,600.00 0-- cannot be billed with other decompression codes-- instrumentation and fusion may also be billed607K Hal ring application $900.00 0608K Closed reduction and traction $690.00 0609K Halo jacket $346.00 0610K Thoracolumbar bracing $460.00 0Tumour/Infection/Vascular616K Major decompression code -- add 30 percent of Decompression617K Excision of mass without decompression $510.00 42 M618K Excision of mass with nerve root decompression 30 percent of Posterior Decompression-- see posterior decompression -- add 30%619K Removal intradural/extramedullary tumour $3,452.00 42 HCannot be claimed with other decompression codes620K Removal of intradural/intramedullary tumour $4,072.00 42 HCannot be claimed with other decompression codes621K Excision of intradural vascular malformation $3,500.00 42 HCannot be claimed with other decompression codes622K Interruption of spinal dural AV fistula $2,600.00 42 HCannot be claimed with other decompression codes623K Percutaneous vertebral biopsy $346.00 42 M624K Open vertebral biopsy $500.00 42 MPain630K Implantation of a single quadripolar electrode $1,726.00 42 M631K -- additional quadripolar electrode $690.00 42(Maximum of 1 additional electrode)632K Implantation of a single quadripolar electrode $2,032.00 42 M-- if surgery in same area as a previous surgery633K -- additional quadripolar electrode -- if surgery $734.00 42in same areas as previous surgery(Maximum of 1 additional electrode)634K Implantation of octopolar electrode $1,840.00 42 M635K -- additional octopolar electrode $690.00 42(Maximum of 1 additional electrode)636K If laminectomy required for electrode insertion $1,730.00 42 M-- 8 contacts637K -- 16 contacts $2,070.00 42 M638K Internalization of stimulation system $576.00 42 M-- non-rechargeable639K -- rechargeable $806.00 42 M640K Removal of stimulating electrode $460.00 42 M641K Adjustment of stimulating electrodes $914.00 42 M642K Programming of pump $230.00 42643K Programming of pulse generator $230.00 42644K Myeoltomy for pain -- open or percutaneous $2,000.00 42 HCannot be claimed with other decompression codes645K Pain pump implantation $1,726.00 42 M646 K Dorsal root entry zone lesioning or percutaneous $2,200.00 42 HCT guided cordotomy647K Repair or replacement of blocked intrathecal catheter $1,036.00 42 MSMA FEE GUIDE - K7 - April 1, 2012

SECTION K:NEUROSURGERYFeeAnae648K Reanchoring a flipping pump $690.00 42 M649K Replacement of pain pump $920.00 42 M650K Removal of pain pump and catheters . $690.00 42 M651K Replacement of Pulse generator -- rechargeable $806.00 42 M652K Replacement of Pulse generator $576.00 42 M-- non-rechargeableMiscellaneous658K Vertebroplasty $1,188.00 42 M659K -- each additional level -- add $400.00 42(Maximum of 3 additional leels)660K -- in addition to another spinal procedure $452.00 42661K Kyphoplasty $1,840.00 42 M662K -- each additional level -- add $1,150.00 42(Maximum of 1 additional level)663K -- in addition to another spinal procedure $600.00 42664K Spinal duraplasty $566.00 42 M665K Syringosubarachnoid shunt $1,800.00 42 H666K Syringopleural or syringoperitoneal shunt $2,200.00 42 H667K Management of intradural congenital lesion $2,240.00 42 H-- includes diastematomyelia, tethered cord,lipoma668K Intradural rhizotomy $2,200.00 42 H669K Meningocele repair $1,464.00 42 M670K Myelomeningocele repair $1,956.00 42 M671K -- if plastic surgeon performs closure $1,000.00 42 M331K Team Spinal Surgery -- where procedures requires 50 percent of Firstthe presence of two spine surgeons working inSurgeon's Claimequal capacity - not for routine assisting.-- Can be billed by all neurosurgeons andand orthopaedic surgeons.Premiums677K Acute spinal cord injury (ASIA, A, B or C 15 percent of Surgeryless than 6 weeks)678K Monitoring $600.00 42- Electromyogram (EMG)- Motor Evoked Potentials (MEP)- Somatosensory Evoked Potentials (SSEP)679K Spine surgery supplement for patients with a $336.00Body Mass Index, (Weight [kg]/Height[m]2)greater than 40- Maximum of one 679K supplement perpatient per day.- Supplement 679K may be billed by spinesurgeons with all K Section spine proceduresdone in the operating room.680K Spinal stereotaxy for tumor, trauma, revision, $1,150.00 42 Mpediatric, and greater than 3 levels of deformity681K Revision surgery -- add 30 percent of Decompression682K Revision surgery -- add 30 percent of FusionSMA FEE GUIDE - K8 - April 1, 2012

SECTION L:GENERAL SURGERYVisitsWhen the words 'Fee for Service' or 'By Report' are shownrather than a specific rate of payment, the followingapplies:(a) Fee For Service-- means services are to be biled onthe basis of individual appropriate visit or procedureitems included in the Payment Schedule, at the listedamount, and are subject to the Assesment Rules.(b) By Report -- Means that the claim must be accompaniedby a detailed explanation of the circumstances and theservices provided. Payment will be assessed on the basisof the explanation. These claims must be submitted onclaim forms.(c) Out of Hours Premiums see -- A36.Fee5L Initial Assessment $113.00-- of a specific condition includes: pertinentfamily history, patient history, history ofpresenting complaint, functional enquiry,examination of affected part(s) or system(s),diagnosis assessment, necessary treatment,advice to the patient and record of service providedAnae7L Follow-up Assessment $68.80 *-- includes: history review, functional enquiry,examination, reassessment, necessarytreatment, advice to the patient and record of service providedGeneral, Thoracic and Vascular9L Surgery Consultation $216.00-- includes all visits necessary, history andexamination, review of laboratory and/or other dataand written submission of the consultant's opinionand recommendations to the referring doctor10L Cardiac Surgery Consultation $294.00(only payable to physicians with approvedtraining in cardiace surgery) -- includes allvisits necessary, history and examination,review of laboratory and/or other data andwritten submission of the consultant's opinionand recommendations to the referring doctor11L -- repeat $107.0013L Written advice to referring physician on the $56.00management of a case based upon review ofdiagnostic imaging (payable once per case only)Hospital Care(Payable on day of admission)25L -- first 10 days, per day $50.40 *26L -- 11-20 days, per day $50.40 *27L -- 21-30 days, per day $22.80 *28L -- thereafter, per day $22.80 *Note: for hospital discharge by physician,see code 725A, page A28ProceduresAdditional payments for diagnostic serviceexcluding ECG's, 0, 10 or 42 day operativeprocedures performed on patients under one (1) yearof age are automatically calculated and paid asexplained in Section A, pages A34 and A35.SMA FEE GUIDE - L1 - April 1, 2012

SECTION L:GENERAL SURGERYFeeAnaeHead and Neck30L Maxilla-partial resection $1,778.30 42 M31L -- total resection $2,165.70 42 M32L V-excision lip -- less than 1/3 $274.00 * 42 L33L Mandible -- one side at ramus excision $1,082.80 42 M35L -- segmental resection $818.00 42 MTongueRepair of laceration or excision of benigntumor of tongue45L -- local anaesthetic $134.80 * 1046L -- under general anaesthetic or IV sedation $165.90 * 10 M(includes post op recovery)Frenectomy -- See 139TGlossectomy47L -- partial $716.00 42 M48L -- hemi $842.00 42 M49L -- total $1,353.60 42 M50L Excision carotid body tumor $1,246.00 42 H51L -- with bypass or arterial graft $1,637.10 42 H52L Scalenotomy $554.30 42 L53L -- with cervical rib resection $941.60 42 M54L Branchial cyst -- excision $850.00 42 M55L Thyroglossal cyst or sinus or branchial $1,010.00 42 Msinus -- excisionTorticollis56L -- tenotomy $472.00 42 L57L -- resection of a tumor or wide $790.00 42 Lfasciectomy58L Cystic hygroma -- excision $1,592.00 42 H59L Excision of congenital defects, angular or $725.50 42 Mmidline dermoids, branchial remnants, etc.Salivary Glands60L Submandibular or parotid stone removal $134.80 * 10(office procedure)61L Submandibular duct stone -- operative $294.00 * 10 Mremoval62L Parotid duct stone -- operative removal $566.00 * 42 M63L Local excision of parotid tumor and $918.00 42 Mportion of gland without nervedissection64L Full excision of superficial lobe of $1,944.00 42 Mparotid with nerve dissection65L Total parotidectomy $2,270.00 42 M66L Sublingual gland excision $362.00 * 42 L67L Submandibular salivary gland excision $804.00 42 MThyroid68L Aspiration of thyroid gland $59.90 * D69L Needle biopsy of thyroid gland $118.00 * DThyroidectomyIn instances of combined total and partialthyroidectomy, the maximum benefit billed will be atthe rate of 72L for total bilateral thyroidectomy-- Partial70L -- unilateral $1,378.00 42 M71L -- bilateral $1,542.00 42 M-- total77L -- unilateral $1,616.00 42 M72L -- bilateral $2,270.00 42 M78L -- Recurrent $1,848.00 42 MParathyroid75L Parathyroidectomy -- adenoma or hyperplasia $1,704.00 42 M76L -- with mediastinal exploration $2,041.60 42 H775L Parathyroid, reimplantation, add to 72L, 75L, or 76L $242.00 42 HSMA FEE GUIDE - L2 - April 1, 2012

SECTION L:GENERAL SURGERYFeeAnaeBreast(For augmentation or reduction mammaplasty,prosthesis and nipple surgery see items350N to 431N, 390N, 391N)79L Breast cyst aspiration -- each to a $41.00 * Dmaximum of 4679L Tru-cut needle biopsy of breast $81.20 * D80L Abscess -- single or multilocular $332.00 * 42 L-- general anaesthetic82L Segmental resection $494.00 42 L83L Excision of tumor or biopsy $394.00 10 L86L Excision of non-palpable breast lesion $712.00 10 Lusing wire localization84L Simple mastectomy $996.00 42 M85L Modified radical mastectomy $1,860.00 42 M87L Radical mastectomy $1,986.00 42 M88L -- with skin graft $2,096.0089L Subcutaneous mastectomy with preservation $1,064.00 42 Lof nipple and areolaThorax90L Mediastinoscopy -- without biopsy $474.00 D M689L -- with biopsy $628.00 10 M690L Mediastinotomy. $260.00 42 M91L Funnel chest repair $1,414.50 42 M92L Thoracotomy -- with or without biopsy -- $890.00 42 H(not billed in addition to thoracic surgery)Transthoracic exposure of lowercervical or thoracic spine for neurosurgicalprocedure -- see Section K, Exposures for Neurosurgery93L Thoracotomy for cardiac -- referred $758.00 42 H94L Sternal wound dehiscence, closure (service $393.80 * 42 Mexempt from repeat surgical rule)95L Closed drainage of chest $364.00 * 0 L96L Open drainage of chest with rib resection $542.00 0 MIntrapleural adhesions97L -- endoscopic resection $474.00 42 M98L Poudrage of chest $498.00 42 M99L Decortication lung $1,772.00 42 HLobectomy -- lung100L -- total or segmental $2,002.00 42 H101L -- wedge resection - one $1,572.00 42 H103L -- each additional to a maximum of 3, add $206.00 42600L Sleeve lobectomy $2,260.00 42102L Pneumonectomy $2,086.00 42602L Sleeve pneumonectomy $2,250.00 42Biopsy of lung106L -- open $936.00 42 H107L -- needle $239.70 DDrainage lung abscess108L -- one stage $964.00 42 H109L -- two stages $1,004.00 42 H110L Resection first rib $926.00 42 MThoracoplasty111L -- without first rib $1,648.90 42 M112L -- with first rib $1,250.00 42 M113L Thoracoplasty -- second stage $666.00 42 MMediastinal tumor includes thymectomy114L -- removal $1,546.00 42 H115L -- radical excision $2,014.00 42 HHeart -- Closed Operations116L Exploratory cardiotomy -- (not billed in $1,168.40 42 Haddition to thoracic surgery)117L Insertion of cardiac pacemaker via $1,168.40 42 HthoracotomyImplantation of transvenous pacemaker or AVsequential pacemaker (includes programming)SMA FEE GUIDE - L3 - April 1, 2012

SECTION L:GENERAL SURGERYFeeAnae120L -- permanent ventricular (one lead) $860.00 42 L820L -- permanent AV sequential (two lead), add $250.00 42 L121L -- temporary $316.00 0 LSee Section D, Pacemaker Clinic Services122L Replacement of pacemaker power pack (service $470.00 42 Lexempt from repeat surgical rule)622L Reinsertion or repositioning of temporary $147.70 0 Hpacemaker123L Pericardiectomy $1,800.00 42 H124L Patent ductus arteriosus -- ligation or $1,414.50 42 Hdivision126L Mitral valvuloplasty -- closed $1,648.90 42 H127L Blalock, Potts or Glenn procedure $1,186.00 42 H128L Cardiac wound repair $1,168.40 42 H129L Pericardial window $941.60 42 H130L Operative implantation of intra-aortic $603.50 0 Hballoon pump131L -- removal $308.20 0 H132L Percutaneous intra-aortic balloon $328.00 0 Hpump -- insertion (includes removal)135L Thoracotomy for post-operative hemorrhage $879.50 42 H(service exept from repeat surgical rule)137L Vascular ring $1,133.00Procedures With Cardio-Pulmonary Bypass138L Aorto-coronary bypass with tissue $1,072.00 42 Hstabilizing device161L Extracorporeal bypass $1,072.00 42 H139L Banding of pulmonary artery $904.00 42 H140L Pulmonary stenosis $1,696.00 42 H141L Pulmonary embolectomy $1,772.00 42 H142L ASD, secundum $1,932.00 42 H143L ASD, primum $1,987.00 42 H144L ASD, communis $1,987.00 42 H145L VSD, (direct closure or patch) $1,987.00 42 H146L Tetralogy, complete repair $1,902.00 42 H147L Aorto-pulmonary window closure $1,934.00 42 H148L Total anomalous pulmonary venous return $1,863.90 42 H149L Aortic valve replacement $3,900.00 42 H150L Mitral valve replacement $3,800.00 42 H100% -- 1st valve75% -- each subsequent valve151L Mitral valvuloplasty -- direct vision $2,274.00 42 H152L Aortic valvuloplasty -- direct vision $2,362.00 42 H652L Bental procedure (modified) -- includes 149L $6,500.00 42 H188L, 189LX2 and 161L653L Amplatzer device closure of arterial septal $1,662.00 42 Hdefect (does not include angiographyif required)Aorta-coronary bypass graft153L -- single $2,700.00 42 H154L -- for each additional $566.00 42 H155L -- each coronary endarterectomy, add $566.00 42 H755L Coronary patch angioplasty greater than 3 cm $760.00 42 Hin length (includes endarterectomy) -- add654L Use of internal mammary artery for bypass $350.00 42graft, add655L Use of radial artery for bypass graft, add $360.00 42156L Excision of ventricular aneurysm $1,950.60 42 H956L Tricuspid annuloplasty or valvuloplasty $2,069.00157L Procuring heart/heart valves for transplant $564.00 0 M760L Implantation of cardiodefribillator (ICD) $1,600.00 42 Hany method761L Radiofrequency of atrial fibrillation -- add $1,000.00 42 H762L Implantation of bi-ventricular pacing $600.00 42 Hdevice -- addSMA FEE GUIDE - L4 - April 1, 2012

SECTION L:GENERAL SURGERYFeeAnaeVEINSPortacath, infusaport, hemocath,Hickman-Broviac for chemotherapyor long-term T.P.N.657L -- insertion $462.00 10957L -- if second incision, add $157.00658L -- remove and replace $666.00 10659L -- remove or revise, same site $276.00 * 0730L Intravascular thrombolysis attendance $922.00 10 Land standby158L Transvenous insertion of intra atrial $154.00 0 Lpediatric feeding catheter458L Insertion of vena-cava filter $576.00 42 L160L I.V. cutdown $70.20 * 0 L231L Insertion of Leveen/Denver shunt $1,744.00 42 H182L Ligation or plication of iliac, $1,046.00 42 Hor inferior vena cava183L Ligation of femoral vein $524.00 42 M162L Venous shunt - portocaval, splenorenal, $2,590.50 42 Hmesocava186L Transthoracic ligation of oesophageal $1,390.00 42veinsVenous Thrombectomy166L -- trunk $1,056.00 42 H459L -- vena cava - tumor thrombus $1,730.00 42 H167L -- extremity - deep vein $814.00 42 MRepair of Wounds^Major Artery or VeinTrunk175L -- suture $1,244.00 42 H176L -- graft $2,066.00 42 HMajor Artery -- Extremity or Neck177L -- suture $836.00 42 M178L -- graft $1,324.00 42 MMajor Vein -- Extremity or Neck179L -- suture $508.00 42 L180L -- graft $954.00 42 L^ If saphenous vein graft add 769L. Unlisted or unusually complicated -- by reportDigital Vessel RevascularizationMicrovascular or loupe magnification revascularizationof a digital vessel as part of a wound repair281L Revascularization -- arterial $1,300.00 42 H282L Revascularization -- arterial -- with vein graft $1,500.00 42 H283L Revascularization -- venous $1,300.00 42 H284L Revascularization -- venous -- with vein graft $1,500.00 42 HCodes 281L to 284L only apply when provided by a recognizedmicrovascular unit. Each individual code is billable once peranatomical site. The 75% rule will apply where all attempts torevascularize fail.Renal660L Haemodialysis - cutdown artery $83.60 0and vein661L Schribner or similar shunt, $362.00 42initial or repeat662L A/V fistula for dialysis $696.00 42663L Arterial venous fistula with $1,064.00 42graft -- prosthetic or venous(includes harvesting of vein)666L Ligation of fistula $400.00 0SMA FEE GUIDE - L5 - April 1, 2012

SECTION L:GENERAL SURGERYFeePeritoneal Dialysis667L Chronic dialysis catheter -- insertion $444.00 * 0669L -- removal $292.00 * 0670L Acute dialysis catheter insertion $154.00 0includes first 24 hours of dialysis671L Externalization of buried chronic peritoneal $291.00 0dialysis catheterAnaeArteries159L Biopsy of artery $280.00 * 10 L181L Ligation of carotid artery $520.00 42 H184L Exploration of peripheral artery $364.00 42 M187L Coarctation of aorta repair $1,846.00 42 HBypass Graft (Occlusive Disease or Aneurysm)769L is billable in addition for harvesting oflong saphenous - 770L is billable if in situsaphenous vein preparation769L Harvesting long saphenous vein $276.00 42for use in peripheral vascularsurgery, add770L In situ saphenous vein preparation, add $546.00 42Bifurcation Grafts^568L Aorto-iliac - unilateral or bilateral $2,808.00 42 H668L Aorto-unifemoral $2,719.90 42 H768L Aorto-bifemoral $2,935.00 42 H460L Juxta-renal aortobifemoral $3,850.00 42 H461L Ilio-femoral obturator $1,960.00 42 H^ Includes thromboendarterectomyand/or embolectomy191L Ruptured aortic aneurysm $640.00 42 H(add to surgical procedure)Peripheral Artery169L Femoro-popliteal $1,500.00 42 H462L Femoro-tibial or peroneal $1,966.00 42 H463L Femoro-pedal $2,246.00 42 H464L Axillo - axillary, axillo-femoral; $1,696.00 42 Hcarotid-subclavian; cross femoral;ilio-femoral; subclavian-subclavian;other arteries of neck or extremitiesThoracic or abdominal aorta188L Aorto-carotid; aorto-axillary; aorto-coeliac; $2,670.00 42 Haorto-superior mesenteric; aorto-innominate;renal; thoracic or abdominal aorta189L Reimplantation of each major branch, add $374.00 42 H174L -- intra-operative arteriogram, add $159.00 * DComplication of GraftsRepeat graft - within 42 days - 75%- after 42 days - 150%Bypass graft with thromboendarterectomy.A thromboendarterectomy at site of a regulararterial bypass is included in the compositefee. However, where thromboendarterectomyof extensive atherosclerosis of profundafemoris artery is carried out in additionto aorto uni or bifemoral graft the followingshould be claimed by report.790L Aorto femoral - unilateral with $3,788.00 42 Hthromboendarterectomy ofprofunda femorisSMA FEE GUIDE - L6 - April 1, 2012

SECTION L:GENERAL SURGERYFeeAnae791L Aorto femoral - bilateral with $4,070.00 42 Hthromboendarterectomy of profundafemoris465L Profundoplasty - (sole procedure) $1,496.00 42 HProfundoplasty up to the first majorbranch is included in the fee for bypassprocedure. If a bypass graft is accompaniedby a profundoplasty extending beyond thefirst major branch of the profundo femorisartery, add 466L to the bypass fee.If the repair extends beyond the secondmajor branch, add 467L. Payment forprofundoplasty includes thromboendarterectomy.Claim 465L if a profundoplasty is done alone.466L Profundoplasty beyond first major $802.00 42 Hbranch, add467L Profundoplasty beyond second major $1,000.00 42 Hbranch, addArteriotomy with Embolectomy163L -- trunk $1,378.00 42 M164L -- neck $1,074.00 42 H165L -- extremity $1,030.00 42 M468L -- visceral $1,698.00 42 HThromboendarterectomy(Independent Procedure)469L Femoral (unilateral) $1,592.00 42 M470L -- iliac; carotid; renal; subclavian; $1,764.00 42 Hsuperior mesenteric; vertebral471L -- aorta innominate $2,538.00 42 H472L -- aorto-iliac - unilateral or $2,666.00 42 Hbilateral; aorto ilio-femoralunilateral473L -- aorto ilio-femoral, bilateral $3,048.00 42 H474L Carotid endarterectomy with patch angioplasty $712.00 42 Hgreater than 3 cm -- add920L Vascular Re-do Procedure -- add to 163L, 164L, 165L, 169, 188L, 460L, 461L, $400.00 42 H462L, 463L, 464L, 465L, 468L, 469L, 470L, 471L, 472L, 473L,668L, 768L, 790L, 791LExcision AV fistula192L -- extremity $910.00 42 L193L -- trunk $1,594.00 42 MVaricose VeinsSaphenous axis -- section and ligation200L -- unilateral $418.00 * 42 L201L -- bilateral $794.00 * 42 LLigation of multiple veins, with orwithout long saphenous stripping,with saphenous axis ligation209L -- unilateral $738.00 * 42 L210L -- bilateral $1,432.00 * 42 L211L Multiple ligation of veins -- each $72.20 10 L-- maximum - 10 veins212L Endovenous Laser Therapy (excludes $782.00 42transcutaneous laser treatment of spider veins) …..-- Payment will only be made for services providedin hospital (including outpatient setting) fortreatment of major varicosities of the lesser andgreater saphenous systems, which couldotherwise require surgical stripping.Ligation and dissection short saphenous veinat saphenopopliteal junctionSMA FEE GUIDE - L7 - April 1, 2012

SECTION L:GENERAL SURGERYFeeAnae213L -- unilateral $352.00 * 42 L214L -- bilateral $522.00 * 42 L215L Subfascial ligation of one incompetent $113.40 * 0 Lcommunicating veinFollow-up operation to 209L or 210L216L -- unilateral $308.20 * 42 L217L Subfascial ligation -- complete (Linton) $941.60 42 LInjection of symptomatic varicose veins(Injection of spider veins is uninsured)218L -- first vein $80.30 * 0 L618L -- each additional vein $59.90 * 0(one leg max. 15, both legs max. 25)219L Stripping and ligation of short $596.00 * 42 Lsaphenous veinAbdomenTransabdominal exposure of lumbar andlower thoracic spine for neurosurgicalprocedure -- see Section K, Exposures for NeurosurgeryLaparotomy220L -- diagnostic - including removal of $922.00 * 42 MF.B., such as I.U.C.D. - (Not paidin addition to abdominal surgery)531L -- extended - including gland and liver $1,356.00 42 Mbiopsies532L -- staged - for Hodgkins Disease - $2,954.00 42 Hincluding biopsies and splenectomy533L -- for acute trauma - by report $1,390.00 42 M-- with repair of bowel534L -- single add $492.00 42 M535L -- multiple and/or resection, add $794.00 42 M536L -- with splenectomy or repair, add $866.00 42 H537L -- with lacerated liver, add $714.00 42 H538L -- with repair of diaphragm, add $426.00 42 M539L -- insertion of tubes and post-operative $326.00 42 Mcontinuous peritoneal lavage, add221L Peritoneoscopy $387.30 D M-- with or without biopsy(Peritoneoscopy if not billable with laparoscopicsurgery unless precedes the surgery as a diagnosticprocedure)222L Abdominal wound dehiscence -- (exempt from $568.00 * 42 Mrepeat surgical rule)Sub-phrenic abscess224L -- incision and drainage $1,482.00 42 MAbdominal or pelvic abscess225L -- incision and drainage $852.00 * 42 M226L Transrectal drainage of pelvic abscess $426.00 * 42 LIncision and drainage of227L -- supra-levator, pelvi-rectal or $526.00 42 Lretro-rectal abscess228L -- ischio-rectal abscess $470.00 * 42 L229L -- perianal abscess $356.00 * 10 L230L Pneumoperitoneum $187.00 0 L231L Insertion of Leveen/Denver shunt $1,744.00 42 H232L Debulking of intra-thoracic or intra-abdominal $944.00 42 Htumor when primary procedure233L Intraoperative surgical intervention $556.00 42 MNote: To be paid to the surgeon when he iscalled in by the primary surgeon during thecourse of the operation and performs asurgical procedure for which there isno listed fee (e.g., adhesiolysis). This serviceis paid as a flat fee. Consultation is not paidin addition. If the surgeon does not haveSMA FEE GUIDE - L8 - April 1, 2012

SECTION L:GENERAL SURGERYto carry out any procedure and only providesadvice, a consultation alone is the proper claim.FeeAnaeHernia Repairs240L Diaphragmatic hernia $1,560.00 42 M241L Fundoplication and/or hiatus hernia repair $1,560.00 42 M242L Epigastric hernia $642.00 * 42 L243L Reduction of hernia $64.20 * 0 L244L -- with anaesthetic. $91.80 0 L245L Incisional ventral hernia $1,116.00 * 42 L246L Massive incisional hernia with Inlay Mesh $1,800.00 42 H247L Paraesophageal hernia repair $2,000.00 * 42 HUmbilical Hernia - not billable in addition to other abdominal surgery exceptwhere clinically indicated and billed by reportUmbilical hernia251L -- child $686.00 * 42 L252L -- adult $740.00 * 42 L253L -- incarcerated or recurrent, child or $966.00 42 MadultOmphalocele255L -- one stage $812.10 42 H256L -- staged -- each stage $822.00 42 H258L Patent urachus -- includes excision of urachal $774.00 42 Mcycst or sinus260L Inguinal or femoral herniorrhaphy $830.00 * 42 L261L -- incarcerated, strangulated or recurrent $970.00 42 M262L Simple herniotomy -- unilateral $730.00 * 42 L263L -- bilateral - includes unilateral herniotomy $996.00 * 42 Lwith negative contralateral exploration(open or by laparascopy)Herniotomy with orchidopexy, only thelarger fee is paid264L Spigelian hernia $864.00 42 L265L Lumbar hernia $918.00 42 L266L Obturator hernia $904.00 42 L267L Patent vitello-intestinal duct or excision $1,060.00 42 MMeckel's diverticulum includes excision ofomphalomesenteric duct fistula, cystor sinusBiliary Tract271L Cholecystostomy $852.00 42 MCholedochostomy272L -- with or without cholecystectomy $1,646.00 42 M273L Cholecysto-enterostomy $1,224.00 42 M274L Choledocho-enterostomy or $1,674.00 42 Mtransduodenal sphincterotomy674L Choledochojejunostomy with Roux-en-Y $2,300.00 42 M275L Repair stricture common bile duct $2,592.00 42 MCholecystectomy276L -- without operative cholangiography $1,200.00 42 M277L -- with cholangiogram $1,342.00 42 M278L Biliary atresia -- exploration with $1,272.00 42 Mcholangiogram - not paid with portoenterostomy- with liver biopsy add 416L at 75%279L Hepatico -- enterostomy - includes portoenterostomy $3,292.00 42 H(Kasai procedure) for bilary atresiaOesophagus and Stomach290L Introduction Barbin-Mousseau tube $890.00 42 L291L Souttar tube insertion $541.40 42 L292L Oesophagomyotomy (Heller) $1,976.00 42 H293L Congenital tracheo-oesophageal fistula - with $1,986.00 42 Hor without esophageal atresia repair- includes esophageal atresia repair withoutSMA FEE GUIDE - L9 - April 1, 2012

SECTION L:GENERAL SURGERYTEF and cervical repair of congenital TEFOesophageal diverticulum294L -- transthoracic repair $1,350.00 42 HPharyngo-oesophageal diverticulum295L -- repair $1,134.00 42 MFeeAnaeRuptured oesophagus296L -- transthoracic repair $1,288.00 42 H297L -- transcervical repair $922.00 42 M298L Oesophagogastrostomy or oesophagojejunostomy $1,984.00 42 MOesophagectomy or oesophagogastrectomy299L -- with or without pyloroplasty $2,966.00 42 H320L -- with replacement $3,614.00 42 H300L Total oesophagectomy with cervical $2,436.40 42 Hfistula and gastrostomy301L Replacement of oesophagus by transplant $2,966.00 42 H302L Vagotomy -- truncal or selective -- $1,146.00 42 Habdominal or thoracic321L Highly selective vagotomy, with or without $1,637.10 42 MpyloroplastyGastrectomy (with or without splenectomy)303L -- partial $1,944.00 42 H304L -- partial with vagotomy $1,976.00 42 H305L -- total $3,126.00 42 H306L Pyloroplasty $1,082.80 42 M307L -- with vagotomy $1,860.00 42 M607L -- with oversewing of bleeding ulcer, add $284.00 42 M308L Gastro-enterostomy $1,112.00 42 M309L -- with vagotomy $1,574.00 42 M310L Gastrotomy -- with or without removal of $1,082.80 42 Mforeign body or tumorGastrostomy311L -- simple $870.00 42 M312L -- with living tube $1,146.00 42 M313L Decompression gastrostomy -- in conjunction $195.00 * 42 Mwith other abdominal surgery, add314L Rammstedt pyloromyotomy $954.00 42 M315L Perforated ulcer -- repair $1,112.00 * 42 M317L Resection of anastomotic ulcer $2,094.00 42 M318L Repair duodenal tear $1,146.00 42 M319L Traumatic duodenal fistula $1,582.00 42 M322L Vertical band gastroplasty for morbid obesity $1,418.00 42 H323L -- with Roux-en-Y $2,044.00 42 H327L Laparoscopic Roux-en-Y Bypass $3,050.00 42 H328L Laparoscopic sleeve gastrectomy $2,000.00 42 H324L Biliopancreatic bypass includes gastric $3,786.00 42 Hhandling and two entero-enterotomiesSmall Bowel330L Perforated small bowel repair $1,216.00 * 42 MSmall bowel obstruction331L -- without resection $1,248.00 * 42 M332L Small bowel resection $1,560.00 42 M333L Appendectomy -- (not paid in addition to $814.00 * 42 Mabdominal surgery, except where clinicallyinidcated and billed by report)334L Entero-enterostomy $1,482.00 42 M335L Enterotomy for foreign body or tumor $1,194.00 42 MIleostomy revision336L -- minor (service exempt from repeat surgical rule) $742.00 42 L337L -- major (service exempt from repeat surgical rule) $1,082.80 42 M338L Feeding jejunostomy $998.00 42 M638L Tube jejunostomy when performed with $498.00 42other surgery339L Continent ileostomy (Koch's) -- $2,176.00 42 Mindependent procedureSMA FEE GUIDE - L10 - April 1, 2012

SECTION L:GENERAL SURGERYFeeAnae639L Closure of loop or double barrelled ileostomy $1,054.00 42 M(service exempt from repeat surgical rule)Bowel Obstruction -- Infant--excluding intussusception631L -- without resection - includes Ladd's $1,365.30 42 Mprocedure for malrotation and/or correction of volvulus632L -- with resection - includes duodenal $1,744.00 42 Matresia repair, repair of jejunoilealatresia (single atresia)Large Bowel340L Caecostomy or enterostomy (service exempt $1,044.00 * 42 Mfrom repeat surgical rule)342L Colectomy -- hemi or segmental $2,014.00 42 H442L Hartmann's procedure $2,024.00 42 H343L Total colectomy with or without ileostomy $2,528.00 42 H344L Total colectomy and proctectomy $3,950.00 42 H644L Continent ileostomy (Koch's) -- with 343L $1,136.00 42 Hor 344L, add645L Total colectomy with mucosal proctectomy $4,540.00 42 Mand ileo-pouch with ileo-anal anastomosisand loop ileostomy345L Ileorectal anastomosis $1,518.00 42 M346L Proctectomy $1,146.00 42 M347L Colostomy (service exempt from repeat $1,054.00 42 Msurgical rule)348L Closure of loop or double barrelled colostomy $1,082.80 42 M(service exempt from repeat surgical rule)548L Colonic reanastomosis following Hartmann's $2,024.00 42 MprocedureColostomy revision349L -- minor (service exempt from repeat surgical rule) $634.00 42 L350L -- major (service exempt from repeat surgical rule) $1,082.80 42 MAbdomino-perineal resection - includes anytype of pullthrough procedure forHirschsprung's disease352L -- one team -- surgeon $3,020.00 42 H353L -- two team -- abdominal surgeon $2,696.00 42 H354L -- perineal surgeon $1,028.00 42 H355L Proctosigmoidectomy $2,300.50 42 HColotomy356L -- for foreign body $1,296.00 42 M357L -- for tumor $1,424.00 42 M358L Anterior resection $2,328.00 42 H359L Posterior resection $2,372.00 42 HAnus and RectumMassive rectal prolapse365L -- perineal repair $996.00 42 L366L -- abdominal repair $1,418.00 42 M367L -- with sigmoid resection $1,788.00 42 H368L -- abdominal-perineal repair $2,038.00 42 M369L Insertion of ring or wire for rectal $596.00 42 Lprolapse373L Closure of rectovesical or rectourethral $1,365.30 42 Mfistula374L --with colostomy $1,510.00 42 M377L Banding of hemorrhoids -- each $96.00 * 10 L-- (maximum of of three)Hemorrhoids378L -- injection $59.90 * 0 L379L -- incision or excision external $120.00 * 10 Lthrombosed380L Polyp -- anal -- excision $214.00 * 10 L381L Hemorrhoidectomy $686.00 * 42 LSMA FEE GUIDE - L11 - April 1, 2012

SECTION L:GENERAL SURGERYFeeAnaeImperforate anus383L Low imperforate anus repair $1,316.00 42 M384L High imperforate anus repair - by any method $1,708.00 42 Mincludes division of vaginal, uretheral orbladder fistula386L Rectal polyp or tumor -- excision or $284.00 * 42 Lfulguration -- under anaesthetic387L Transanal excision of giant villous $918.00 42 Madenoma of rectum388L Deep transrectal or perirectal biopsy for $270.70 10 LHirschsprung's disease389L Excision sacro-coccygeal teratoma $1,418.00 42 MPilonidal391L -- cyst or sinus -- excision or marsupialization $756.00 * 42 L394L Major anal sphincter repair for stricture $1,148.00 42 Mor incontinence396L Fissure-in-ano -- incision or excision $474.00 * 42 Land/or subcutaneous sphincterotomyFistula-in-ano -- excision397L -- superficial $620.00 * 42 L398L -- deep involving sphincter $954.00 * 42 L399L -- high $1,146.00 42 L562L Fissure-in-ano -- cleansed and $414.00 * 10 Lobliterated with Tiseel400L Anal dilatation - Manual or by balloon $111.00 * 0 L(under anaesthetic or IV sedation) (includespost op recovery)Not to be billed with other anorectal surgerysuch as hemorrhoidectomy, fissure codes etc.Liver, Spleen, AdrenalsLiver413L -- rupture -- repair $1,440.00 42 H414L -- abscess -- incision and drainage $1,216.00 42 M415L -- needle biopsy $179.00 D L416L -- open biopsy $902.00 42 M417L -- hemi-hepatectomy $3,292.00 42 H418L -- segment hepatectomy $1,895.00 42 HPancreatectomy419L -- partial $1,895.00 42 H420L -- partial with duodenectomy or total $3,694.00 42 Hwith or without duodenectomy421L Pancreatic pseudocyst marsupialization $1,722.00 42 Mor adenoma excision620L Pancreatic abscess drainage $1,278.00 42 M621L Pancreatico-enterostomy with Roux-en-Y $2,756.00 42 MSplenectomy422L -- abdominal or repair $1,560.00 42 M423L -- thoraco-abdominal $1,560.00 42 MAdrenal -- exploration424L -- unilateral $1,895.00 42 M426L Adrenalectomy -- unilateral $1,704.00 42 H428L Extra-adrenal phaeochromocytoma or $2,160.00 42 Hother retroperitoneal tumorLymph NodesBiopsy430L -- superficial node $183.00 * 10 L431L -- deep node -- beneath deep fascia $326.00 * 10 L432L -- scalene node $408.00 10 L433L -- mediastinal $596.00 10 M434L Suprahyoid block dissection $1,194.00 42 M635L Sentinel lymph node biopsy - with malignant $1,014.00 42 Mmelanoma and breast cancer surgery73L Central neck dissection - thyroid cancer - add to 72L $550.00 42 MSMA FEE GUIDE - L12 - April 1, 2012

SECTION L:GENERAL SURGERYFeeAnaeComplete block dissection435L -- neck $2,176.00 42 H436L -- axilla $1,338.00 42 M437L -- groin-wide inguinal $1,478.00 42 M438L -- groin-deep with common iliac $2,076.00 42 Mdissection439L -- retroperitoneal -- including pelvic, aortic and renal $2,388.00 42 H440L Scalene fat pad dissection $642.00 42 LIntegumentary SystemBiopsy of palpable superficial lesion - unlessotherwise listed840L -- by fine needle biopsy or aspiration $59.90 * D L841L -- by core needle biopsy $79.00 * D L849L Aspiration of haematoma or cyst $41.40 * 0 L850L Incision and drainage of abscess, etc. $104.00 * 10 L851L Abscess -- multilocular $125.00 * 10 L852L Carbuncle, deep (beneath deep fascia) or $179.00 * 10 Lpilonidal cyst abscess -- unroofingunder general anaesthetic853L Intramuscular abscess By Report 10 L854L Muscle biopsy $230.00 * 10 LAblation of actinic keratosis, pyogenic granuloma,keratoacanthoma or bleeding lesions byelectrocautery, chemical cautery, cryotherapy,laser and/or curettageAbalation of seborrheric keratosis, molluscumcontagiosum, skin tags and warts603L - first lesion $47.80 * 10 L604L - second to seventh, each $18.60 * 10 L605L - eighth and over, each $7.20 * 10 L(Veneral Warts, see codes 420R to 422R)610L Laser ablation of actinic keratosis, pyogenic $134.00 * 10 Lgranuloma, keratoacanthoma, plantars warts,bleeding lesions under local anaesthesia --laserowned by physician-- first 15 minute session611L Each subsequent 15 minutes (maximum of two $79.20 * 10 Ladditional units), addPulsed dye turned laser ablation of facial port-winestains is insured under the age of 18. Pre-authorizationrequired for other symptomatic or bleedingcurtaneous angiomata.795L -- removal by electrocautery or laser under local anesthesia - first lesion $50.30796L - second to seventh, each $18.60797L - eighth and over, each $7.90798L -- laser therapy of cutaneous lesions in $125.00 10physician's office - laser owned by physician- first 15 minute session799L - each subsequent 15 minutes to a $62.20 10maximum of two additional, add780L Dye-tuned laser ablation of cutaneous lesion $101.70 * 0- laser owned by physician- per 15 minute session or majorpart thereof781L - for each unit of up to five pulses, add $14.80 * 0(Note: Billings also to be made in units; 1 unit = 5 pulses)Lesion removal by surgical excision with suture closure:the various diameter categories below relate tothe size of the lesion, not the size of the excision-- under 1 cm. diameter -- any areaSMA FEE GUIDE - L13 - April 1, 2012

SECTION L:GENERAL SURGERYFeeAnae857L -- 1st lesion $104.00 * 10 L858L -- 2nd to 7th, each . $51.60 * 10 L859L -- 8th and over, each $34.60 * 10 L-- over 1 cm. diameter--face, palm of hand or fingers, sole offoot or toes860L -- 1st lesion $161.00 * 10 L861L -- 2nd to 7th, each $80.80 * 10 L862L -- 8th and over, each $53.60 * 10 L-- over 1 cm. diameter--other areas, including scalp863L -- 1st lesion $119.00 * 10 L864L -- 2nd to 7th, each $58.60 * 10 L865L -- 8th and over, each $34.80 * 10 LSebaceous cyst or intradermalcyst (any area)866L Excision and suture closure $141.00 * 10 LLipoma or subcutaneoustumor -- excision867L -- up to 5 cm. $138.00 * 10 L868L -- over 5 cm. up to 10 cm. $228.00 * 42 L869L -- larger than 10 cm. $460.00 * 42 LLipomas are only insured when medically necessary(ie. Initial biopsy or causing symptoms in functionalarea) -- maximum of four services.Beneath deep fascia870L Lipoma or other benign tumor $688.00 42 L871L Malignant tumor By Report 42 MRemoval of Foreign Body-- without anaesthesia Visit Fee872L -- under local anaesthesia $176.00 * 10 L873L -- under general anaesthesia or IV sedation $228.00 * 10 L(includes post op recovery)874L -- complicated By Report 42 L974L Removal of deep metallic foreign body $294.00 * 10 Lunder x-ray or fluoroscopic guidancePlantar warts -- Excision or fulgurationplus curettage875L -- 1st lesion $56.20 * 10 L876L -- each additional (maximum of 4) $18.80 * 10 LPlantar warts -- Treatment by cryotherapylaser, cautery or or chemical ablation877L -- 1st lesion $27.80 * 10 L878L -- 2nd to 7th, each (max. of 6 units for this code) $10.80 * 10 L879L -- 8th and over, each $3.20 * 10 LRemoval of fingernail or toenail880L -- simple avulsion or wedge excision $112.00 * 10 L881L -- radical excision of nail bed or $278.00 * 10 Lhemiphalangectomy882L -- wedge resection with phenol ablation $197.00 * 10 Lor cautery or cryo ablation883L Trimming of toenails, corns or calluses where $36.80 * 0 Lmedically necessary (max. of 1 per day)884L Soft tissue nail-fold excision for ingrown toenails -- Vandenbos surgery $240.00 10 LSMA FEE GUIDE - L14 - April 1, 2012

SECTION L:GENERAL SURGERYLacerations -- Repair of lacerations - whereapproximation of would edges needs to beachieved and maintained.(Laceration repair is categorized below by bodylocation. When billing for multiple repairs addthe lengths of all individual lacerations for thesame location category, i.e., (A) or (B), and submitas a single total laceration under the appropriatecode(s). Where lacerations involve both locationcategories apply the same procedure withineach category).FeeAnae(A) -- face, palm of hand, fingers, soleof foot or toes890L -- up to 2.5 cm. $111.00 * 10 L891L -- each additional 2.5 cm. $55.00 * 10 L(B) -- other areas, including scalp894L -- up to 2.5 cm. $73.60 * 10 L895L -- each additional 2.5 cm. $36.80 * 10 L896L -- complicated - times and details must be provided By Report 42 L897L Tray service --only for office procedures which $34.20 *require sutures or staples, the use of sterilizedinstruments and are performed under localanaesthetic e.g. excision of skin lesions withsutures or staples, biopsies requiring localanaesthesia and sutures or staples, wedgeresection of toenails, vasectomy, sigmoidoscopyor endometrial biopsies (can be paid in additionto the following office procedures only 117A,100F with sutures, 102F with sutures, 45L, 159L,430L, 449L, 450L, 854L, 857L, 860L, 863L, 866L,867L, 872L, 880L, 881L, 882L, 890L (with suturesor staples), 894L (with sutures or staples), 380N,382N, 31P, 39P, 59R, 190R, 72S, 89S or 100S)899L Minor tray service -- -- only for office procedures $17.00 *which require two of suturing, the use ofsterilized instruments or are performed underlocal anaesthetic, -- only payable with thefollowing procedures 123A, 100F withoutsutures, 102F without sutures, 888F, 94H,158H, 379L,380M, 381M, 382M, 108P, 63S,91S, 92S, 250S and 88T898L Removal of sutures from lacerations or sugical $35.00 * 0incisions of any length by any physician700L Surgical debridement; excision of damaged By Report 10necrotic or otherwise non-viable tissue- payment will include payment foroffice tray service where applicable(This item is not billed in addition to burns orcomplicated laceration suture, see code 896L)Physician must provide times and details ofprocedure.For a claim to be processed, the physician must provide details of:i) the patients clinical conditionii) the treatment or procedure providediii) time when the debridement started and was completedPenetrating wound (e.g. gunshotor stab wound)720L -- of chest FFS 42 H721L -- of abdomen FFS 42 MSMA FEE GUIDE - L15 - April 1, 2012

SECTION L:GENERAL SURGERYFeeAnaeInternalization of Epidural Catheter725L -- tunnelling $450.00 10 L726L -- establishment and connection of $214.00 0 LcatheterBurns -- Emergency Treatmente.g. as out-patient 5B or 918A(also see Section N, Burns)Vascular Laboratory(applies to ultrasound vascular studies done inan approved hospital based Vascular Laboratoryonly)Peripheral Arterial750L Resting arterial assessment -- to include multiple $30.00 * Dwave form and/or segmental pressure analysiscalculation and ankle/arm index751L Reactive hyperemia with sequential pressure $30.00 * D752L Vasospastic assessment -- to include digital $30.00 * Dpressures and/or plethysmography, cold andhot stress responses and /or multiple extremitywave form analysis753L Sympathetic tone response --to include resting $30.00 * Darterial assessment plus plethysmography andor impedence monitoring and/or digital waveforms, response to Valsalva monoevers or otherstimuli756L Digital index assessment (finger or toe), PPG wave forms, pulse volume $24.80 Drecordings (not including resting arterial ankle brachial indexes)Peripheral Venous754L Laboratory assessment for interpretation of $30.00 * Dperipheral venous systemBMI Supplement580L General surgery supplement for patients with a $114.00Body Mass Index, (Weight[kg]/Height[m]2)greater than 40- Maximum of one 580L supplement perpatient per day.- Supplement 580L may be billed by all physicians with all Section Lprocedures done in the operating room- Supplement 580L may be billed by generalsurgeons with all L Section procedures donein the operating room.- Bariatric surgery fee codes (322L, 323L, 324L)are exempt from this supplement.General Surgery - EndoscopyENDOSCOPYPreamble-- Base fees include full endoscopic exam with or without biopsies.-- Biopsy for Barrett's esophagitis and inflammatory bowel disease arelisted in endoscopic interventions.-- Cryotherapy for bleeding from polypectomy site is included inpolypectomy code.402L Oesophagoscopy -- base $168.00 * D L403L -- Bleeding varices management (banding, $236.00 * Dsclerotherapy, glue, endoloops, hemoclipsor other) - any combination -- add404L -- Removal of benign tumor -- add $117.00 * D-- Dilatations via endoscope405L -- by means of pneumatic bag or balloon, with $234.00 * Dor without thread or wire guidance -- addSMA FEE GUIDE - L16 - April 1, 2012

SECTION L:GENERAL SURGERYFee406L -- by means of sound or bougie -- add $121.00 * D407L -- Stenting with or without dilatation -- add $242.00 * DAnae408L Gastroduodenoscopy -- base $250.00 * D Lincludes oesophagoscopy409L Management of bleeding (varices, ulcers, GAVE $242.00 * DBanding, sclerotherapy, glue, endoloop, hemoclipsor other) - Any combination of above -- add412L Dilatation of pylorus -- add $117.00 * D410L Nasojejunostomy tube placement -- add $121.00 * D411L Extended enteroscopy -- add $242.00 * DEndoscopic Ultrasound490L Upper endoscopic ultrasound - base $500.00 D L492L Lower endoscopic ultrasound - base $300.00 D L495L Fine needle aspiration biopsy - one or more - add $100.00 D L496L Injection of one or more metastases, nodes, masses or celiac plexus-add $306.00 D L497L Drainage of pseudo cyst, one or more-add $400.00 D LPercutaneous gastrostomy under gastroscopiccontrol -- by two physicians-- endoscopic gastrostomy or jejunostomy443L -- 1st physician $362.00 * 0 L444L -- 2nd physician $242.00 * 0 L-- endoscopic gasterostomy and jejunostomy same day445L -- 1st physician $542.00 * 0 L446L -- 2nd physician $362.00 * 0 LPEG tube change447L External approach PEG tube removal -- external $48.20 * D Lvia gastroscope448L Colonoscopy -- base $388.00 * D L451L Dilatation of colonic anastamotic side -- add $117.00 * D449L Sigmoidoscopy (Flexible) - base code $135.00 * D L450L Sigmoidoscopy (Rigid) - base code $68.80 * D Lbiopsy - included in base code except:480L -- For inflammatory bowel disease $118.00 * D10 or more specimens -- add481L -- Barrett's esophagus -- 4 or more $60.20 * Dspecimens -- addPolypectomy (any G.I. Site) -- by loop,electrocautery, submucosal injection etc.482L -- 1st polyp -- add $121.00 * D483L -- 2nd to 5th polyp each (maximum of 5 total) -- add $91.60 * D484L Sclerotherapy by any thermal means (eg. heater or $117.00 * Dbicapprobe) or any injectable method (eg. Adrenalin,sclerosing solution) or by gluing -- add485L Dilatations -- all G.I. dilatations other than $117.00 * Doesophageal -- pylorus or anastomoticstricture etc. -- add486L Tattoo - any G.I. site -- add $60.20 * D487L Botox - any G.I. or bonchial site -- add $120.00 * D488L Foreign body removal - any G.I. site -- add $121.00 * DUsually complicated or difficult endoscopies by report.500L Endoscopic Retrograde Cholangiopancreatography $458.00 * D L-- baseincludes routine sweeps of common duct -- maximumprocedural billing per base code same day $800.00501L -- plus papillotomy/sphincterotomy -- add $175.00 * D-- with removal of common duct stones and sludge502L -- 1 to 4 stones and/or sludge add $117.00 * D503L -- with removal of 5 or more stones - (includes $234.00 * D1 to 4 stones) -- add504L -- with mechanical lithotripsy -- add $117.00 * DSMA FEE GUIDE - L17 - April 1, 2012

SECTION L:GENERAL SURGERYFee505L -- with brush cystology -- add $58.20 * D-- with Biliary or pancreatic duct balloon dilatations506L -- 1st add $117.00 * D507L -- 2nd add $58.20 * D-- with stenting (any type of stent) -- stent insertion508L -- 1st add $117.00 * D509L -- 2nd add $58.20 * D510L -- stent removal -- one or more add $58.20 * D511L -- stent removal and replacement -- add $117.00 * D512L -- with Brachytherapy catheter placement -- add $108.00 * D513L -- with nasobilary tube placement -- add $116.00 * DAnae520L Bronchoscopy -- (unilateral or bilateral with or $242.00 * D Lwithout biopsy) -- base521L -- with fluroscopy -- add $119.00 * D522L -- with tracheobronchial toilet -- add $121.00 * D523L -- with removal of benign tumor -- add $108.00 * D524L -- with endobronchial malignant tumor $510.00 * Ddebulking -- add525L -- with tracheo esophageal fistula creation -- add $110.00 * D526L -- with removal of foreign body (rigid or $362.00 * Dflexscope) -- add515L Endobronchial Ultrasound Base-includes bronchoscopy-516L may be added $510.00 D516L Transbronchial needle aspiration-add maximum of 3 lesions or stations $102.00 D452L Video Capsule Endoscopy -- 15 minute units -- maximum of 10 units $103.00 DDouble Balloon Endoscopies527L Antegrade Double Balloon Enteroscopy $520.00 D L528L Retrograde Double Balloon Enteroscopy $656.00 D L529L Double Balloon Colonoscopy $574.00 D L530L Double Balloon Endoscopic Retrograde Cholangiopancreatography $656.00 D LSMA FEE GUIDE - L18 - April 1, 2012

SECTION M:ORTHOPAEDIC SURGERYWhen the words 'Fee for Service' or 'By Report' are shownrather than a specific rate of payment, the followingapplies:(a) Fee For Service-- means services are to be biled onthe basis of individual appropriate visit or procedureitems included in the Payment Schedule, at the listedamount, and are subject to the Assesment Rules.(b) By Report -- Means that the claim form must beaccompanied by a detailed explanation of the circumstancesand the services provided. Payment will be assessed on thebasis of the explanation. These claims must be submittedon claim forms.(c) For out of hours premiums see Section A.VisitsFee5M Initial assessment $79.20-- of a specific condition includes:pertinent family history, patienthistory, history of presentingcomplaint, functional enquiry,examination of affected part(s) orsystem(s), diagnosis, assessment,necessary treatment, advice to the patientand record of service provided7M Follow-up assessment $79.20 *-- includes: history review, functionalenquiry, examination, reassessment,necessary treatment, advice to the patient andrecord of service provided9M Consultation $179.00-- includes all visits necessary, historyand examination, review of laboratoryand/or other data and writtensubmission of the consultant'sopinion and recommendations tothe referring doctor10M -- consultation for patients referred for $156.00back pain only11M -- repeat $73.8013M Written advice to referring physician on the $100.00management of a case based upon review ofx-rays by Orthopaedic Surgeon (billableonce per case only)Hospital Care(Payable on day of admission)25M -- first 10 days, per day $44.00 *26M -- 11-20 days, per day $44.00 *27M -- 21-30 days, per day $20.00 *28M -- thereafter, per day $20.00 *Note: for hospital discharge by physician,see code 725A, Section A.SMA FEE GUIDE -M1 - April 1. 2012

SECTION MORTHOPAEDIC SURGERYClassification of Bones for Payment Purposes:Long Short Major Minor Large SmallClavicle x x xHumerus x x xRadius x x xUlna x x xFemur x x xTibia x x xFibula x x xPatella x xMandible x xFacial Bones x xScapula x xPelvis x xVertebra x xOs Calcis x xTalus x xOther TarsalBones x xCarpal Bones x xMetacarpals x x xMetatarsals x x xPhalanges x x xSMAFEEGUIDE -M2- Juriel,2011

SECTION M:ORTHOPAEDIC SURGERYProcedures Fee AnaeAdditional payments for diagnostic serviceexcluding ECG's, 0, 10 or 42 day operativeprocedures performed on patients under one (1) yearof age are automatically calculated and paid asexplained in Section A, Paediatric Age Supplement.BonesIncision30M Incision of deep soft tissue, abscess from $1,000.00 * 10 Losteomyelitis -- billed by reportInternal Fixation RemovalNot paid in addition to or part of anotherorthopaedic procedure unless the internalfixation device is removed from a separateoperative site.31M Removal of percutaneous pins/wires by any $70.00 * 0physician done in an office32M Operative removal of metal bone fixation $233.30 * 10 Ldevice(s), any number of screws, nails orwires per operative site33M -- plate (including screws, intramedullary $650.00 * 10 Lnail)Osteotomy -- with or without internal fixation40M Clavicle $1,050.00 42 L44M Humerus or ulna or radius $1,050.00 42 L48M Radius and ulna $1,050.00 42 L49M Femur -- neck or supracondylar $1,050.00 42 M50M -- trochanteric or subtrochanteric $1,050.00 42 M56M Tibia and Fibula $1,050.00 42 M64M Femur, supracondylar, and tibia and fibula $1,002.60 42 M60M Metacarpal, metatarsal or phalanx -- one $600.00 42 L68M Os calcis (Dwyer or wedge tarsectomy) $1,050.00 42 LExcision81M Biopsy bone $600.00 42 L107M Radio-ulnar synostosis $1,900.00 42 L90M Coccygectomy $800.00 42 LExcision of bone cyst, chondroma or exostosis93M -- large bone $600.00 42 L94M -- with bone graft $700.00 42 L95M -- small bone $500.00 42 L96M -- with bone graft $700.00 42 L98M Partial ostectomy, excision of distal end $500.00 42 Lof ulna or radius .Saucerization and/or sequestrectomy100M -- large bone $682.70 42 L101M -- small bone $450.00 42 LRadical resection of bone for tumor withbone graft103M -- major bone $2,200.00 42 M104M -- minor bone $1,800.00 42 MClaviculectomy83M -- partial $360.00 42 L84M -- total $1,500.00 42 L86M Excision of head of radius $700.00 42 L88M Carpectomy $700.00 42 M89M -- each additional (same field only) $600.00 42 L87M Metacarpectomy or metatarsectomy $700.00 42 L102M Excision of head of femur $744.70 42 MSMA FEE GUIDE -M3 - April 1. 2012

SECTION M:ORTHOPAEDIC SURGERYFeeAnaePatellectomy91M -- partial $436.00 42 L92M -- total $1,300.00 42 L97M Shaving of patella - when only procedure $524.30 42 Ldone85M Astragalectomy $541.40 42 L79M Excision of 4 metatarsal heads (Hoffman) $650.00 42 LBMI Supplement180M Orthopaedic surgery supplement for patients $330.00with a Body Mass Index, (Weight[kg]/Height[m]2)greater than 40. Maximum of one 180M supplement perpatient per day.. Supplement 180M may be billed by orthopaedicsurgeons with all M Section procedures donein the operating room.Introduction110M Insertion of Kirschner wire or metal pins $300.00 * 0 Lfor traction or cast fixation111M Application of caliper or tongs $300.00 * 0 LRepairOsteoplasty -- shortening of bone120M -- femur, tibia or humerus $900.00 42 M121M -- radius or ulna $541.40 42 L122M -- both radius and ulna $1,400.00 42 L123M -- other bones $600.00 42 L-- lengthening of bone124M -- major $1,500.00 42 M125M -- minor (hand or foot) $812.10 42 L126M Acromioplasty includes excision of distal clavicle $744.70 42 LNote: Spinal fusion with partial excision ofintervertebral disc (for excision of discsee 134K to 140K)150M Scapulopexy $1,800.00 42 MEpiphyseal-diaphyseal fusion,epiphyseal arrest or epiphysiodesis152M -- femur or tibia and fibula $900.00 42 L154M -- combined (femur, tibial and fibular) $1,200.00 42 Lepiphyseal arrest155M -- combined (upper and lower tibial $1,200.00 42 Land fibular) epiphyseal arrestFractures1. Definitions(a) Immobilization means the treatment of a fracture by any method other thanthat designated in (b) or (c) below.(b) Closed reduction means the reduction of a fracture by non-operative methods(includes skin traction, K wire or Steinmann's pin for balanced traction).(c) Open reduction means the reduction of a fracture by an operative procedureto include the exposure of the fracture and fixation with intramedullary orother type of appliance.(d) Long bones are clavicle, humerus, radius, ulna, femur, tibia and fibulaSMA FEE GUIDE -M4 - April 1. 2012

SECTION M:ORTHOPAEDIC SURGERY(e) Large bones are the above long bones plus mandible, facial bones, scapula,pelvis, vertebra, patella, os calcis and talus.2. ImmobilizationPayment is made on a fee-for-service basis for non-operativemanagement (conservative treatment) of stable fractures requiringimmobilization only unless otherwise noted in the SMA Guide to Fees.3. ReductionPayment includes all manipulations and re-manipulations toachieve and maintain satisfactory reduction during the designatedpost-operative period.Payment may be made for the reapplication of casts after thedischarge of a hospital in patient. The reapplication of a cast onthe day of surgery is not billable.(a) Payment may be made to a physician who provides emergency care to apatient with a fracture before referral to a specialist.(b) When the attending physician attempts a closed reduction but fails to achievesatisfactory reduction:(i) subsequent closed reduction billed by the same physician (or another physicianin the same clinic and specialty) is deemed to be an inclusion within the paymentmade for the previous attempted reduction.(ii) a subsequent closed reduction by any other physician (not in the samespecialty and clinic) will be billed at 100% and payment for the initial attemptshall be reduced by 50%.(iii) A subsequent closed reduction with external fixation by any physician is paidat 100% and payment for the initial closed reduction shall be reduced by 50%.(c) Open reduction:(i) if a fracture is ununited within the designated post-operative period, and an openoperation with or without bone graft becomes necessary by any physician, thepayment for the original open or closed reduction shall be reduced by 50%.(ii) When a payment for open reduction is not listed, the listing for a closed reductionmay be raised by 50%.(iii) Intramedullary fixation (closed or open) is payable at the same rate as openreduction.(d) Multiple fractures:(i) Multiple fractures requiring closed or open reduction will be paid at 100% forthe major reduction and 75% of the listed payment(s) for the remainder, unless:-- a composite payment is listed for the multiple fractures, or-- a specific payment is listed for the "additional" procedures, or-- a specific assessment rule applies for the type and locale of the fractures.(ii) When multiple major fractures involving different long bones of the same ordifferent extremity occur at the same time, the management of each fractureunder the same anaesthetic may be paid at 100% of the listing unlessspecified otherwise.(e) Unless otherwise listed, the payment for treatment of a compound fracture is theclosed reduction payment plus 50% except where this would exceed the listedpayment for open reduction . The maximum payment for reduction of a compoundfracture by closed or open reduction is the listed payment for open reduction.(f) Payment for open treatment of a fracture which remains ununited after thedesignated post-operative period is based on 150% of the SMA Guide toFees item for primary open reduction.Fracture and Dislocation1. Only the greater listed amount is paid when a Fracture andDislocation are billed for the same day, same site.SMA FEE GUIDE -M5 - April 1. 2012

SECTION M:ORTHOPAEDIC SURGERY2. Unless otherwise indicated, the rules for Fractures and Dislocations apply:(a) on the same day -- to the same physician or another physician in thesame specialty and clinic (or part of the surgical team);(b) during the designated post-operative period -- to the surgeon, a generalpractitioner in the same clinic, or a specialist in the same specialty and clinic.FeeAnaeBone Graft133M Use of bone graft -- autogenous bone add 50%from different site -- add to theamount payable for the procedure done.Cannot be billed for spine surgery cases.134M -- bone bank add 25%oral surgeonCannot be billed for spine surgery cases.135M Harvesting of bone graft for use of $461.20 42 LOral Surgeon136M Extensive harvesting of cadaver bone $1,800.00 42FracturesSpine and TrunkSacrum166M -- operative management $430.10 42 LClavicle173M -- open reduction $850.00 42 LScapula174M -- closed reduction $282.50 * 42 L177M -- open reduction $1,500.00 42 LSternum179M -- open reduction $313.50 42 LPelvis (Ilium, Ischium, Pubis)Fracture192M -- one or more bones -- open reduction $2,000.00 42 M193M -- unstable -- closed reduction with $1,100.00 42 Mexternal fixationAcetabulum -- with or without other fractures of pelvis195M -- central -- with displacement $689.10 42 L196M -- open reduction $2,500.00 42 MUpper ExtremityHumerus-- surgical neck or epiphyseal separation201M -- closed reduction $282.50 * 42 L203M -- open reduction $1,050.00 42 L204M -- shaft -- closed reduction $350.00 * 42 L206M -- open reduction $1,050.00 42 L210M -- reduction with external fixation $904.20 42 LdeviceElbow-- epicondyle only207M -- closed reduction $295.30 * 42 L208M -- open reduction $700.00 42 LDistal end of humerus, proximal end ofradius or ulna, condyle -- one or more bones209M -- closed reduction $313.50 * 42 L212M -- open reduction $1,050.00 42 L214M Supracondylar -- displaced -- closed $406.60 42 Lreduction by manipulation or traction218M Olecranon -- open reduction $600.00 42 LSMA FEE GUIDE -M6 - April 1. 2012

SECTION M:ORTHOPAEDIC SURGERYFeeAnaeRadius-- head220M -- closed reduction $400.00 * 42 L222M -- open reduction $700.00 42 L-- shaft225M -- closed reduction $295.30 * 42 L229M -- open reduction $650.00 * 42 L-- distal end (Colles' including ulnar styloid)233M -- closed reduction $400.00 * 42 L235M -- open reduction $900.00 * 42 L237M Colles -- reduction with external fixation device $550.00 * 42 LUlna-- shaft240M -- closed reduction $295.30 * 42 L243M -- open reduction $600.00 * 42 L244M -- Monteggia fracture -- dislocation $650.00 42 LRadius and Ulna (excluding Colle's)247M -- closed reduction $450.00 * 42 L249M -- open reduction $1,050.00 * 42 L250M -- reduction with external fixation $806.80 * 42 LdeviceCarpal bone251M -- closed reduction $295.30 * 42 L252M -- open reduction $1,050.00 * 42 L253M -- reduction with external fixation $750.00 * 42 LdeviceMetacarpal255M -- closed reduction $400.00 * 42 L257M -- open reduction $700.00 42 L256M Reduction of Bennett's fracture by internal fixation $700.00 * 42 LPhalanx -- finger or thumb260M -- closed reduction $400.00 * 42 L262M -- open reduction $700.00 * 42 LLower ExtremityFemur-- neck291M -- internal fixation $1,300.00 42 MIntertrochanteric295M -- internal fixation $1,300.00 42 M-- slipped epiphysis296M -- closed reduction $748.00 42 L297M -- open reduction -- acute $1,300.00 42 M298M -- reconstructive later $1,500.00 42 M-- shaft -- including supracondylar299M -- closed reduction $689.10 * 42 L303M -- open reduction $1,400.00 42 MPatella305M -- immobilization only $336.00 * 42 L307M -- open reduction or excision -- $700.00 42 Lcomplete or partialTibia-- shaft310M -- closed reduction -- includes $541.40 * 42 Lfibular shaftSMA FEE GUIDE -M7 - April 1. 2012

SECTION M:ORTHOPAEDIC SURGERYFeeAnae312M -- open reduction -- includes $1,000.00 * 42 Mfibular shaft314M -- plateau -- closed reduction $430.10 42 L315M -- open reduction $1,200.00 42 M316M -- malleolus -- closed reduction $295.30 * 42 L317M -- open reduction $650.00 42 LFibula318M -- shaft -- closed reduction $300.00 * 42 L319M -- open reduction $650.00 42 L320M -- malleolus -- closed reduction $492.20 * 42 L321M -- open reduction $650.00 42 L330M Tibia and Fibula -- reduction with $950.00 * 42 Lexternal fixation deviceAnkle -- bimalleolar (including Potts)323M -- closed reduction $313.50 * 42 L325M -- open reduction $900.00 42 L340M -- reduction with external fixation $950.00 42 Ldevice-- trimalleolar326M -- closed reduction $313.50 * 42 L328M -- open reduction $1,050.00 42 L341M -- reduction with external fixation $950.00 42 LdeviceTarsal -- (except astragalus and os calcis)329M -- closed reduction $300.00 * 42 L331M -- open reduction $900.00 42 LAstragalus332M -- closed reduction $300.00 * 42334M -- open reduction $1,050.00 * 42 LOs calcis335M -- closed reduction $300.00 * 42 L337M -- open reduction $1,050.00 42 L338M -- skeletal pinning with external fixation $750.00 42 LMetatarsal339M -- closed reduction $295.30 * 42 L343M -- open reduction $500.00 42 LPhalanx345M -- closed reduction $300.00 * 42 L348M -- open reduction $500.00 * 42 LTreatment of un-united fractures by bonestimulator -- total care350M External application (Bi-Osteogen) $436.00 L351M Percutaneous insertion $879.50 L352M Operative implantation -- add 100% of benefit Mrate for open reduction (50% for ununitedfracture; 50% for operative implantation)-- with bone bank graft -- add 25% of benefitrate of open reduction, under code 134M-- with autogenous bone graft -- add 50% ofbenefit rate of open reduction, under code 133MNote: Specialist in Orthopaedic Surgery onlySMA FEE GUIDE -M8 - April 1. 2012

SECTION M:ORTHOPAEDIC SURGERYFeeAnaeJoints359M Arthroscopy $350.00 D LIncisionArthrotomy or capsulotomy withexploration, drainage or removal of loosebody, e.g. osteochondritis or foreign body360M Shoulder $950.00 42 L361M Elbow $950.00 42 L362M Wrist $950.00 42 L363M Other joints of upper extremity $950.00 42 L364M Hip $950.00 42 L365M Knee $950.00 42 L366M Ankle . $950.00 42 L367M Other joints of lower extremity $950.00 42 L379M Sesamoid bone -- excision -- one or more $162.00 * 42 L-- unilateralArthrocentesis -- puncture for aspirationof joint and/or injection of medication380M -- hip $66.30 * 0 L381M -- shoulder, elbow, knee $49.00 * 0 L382M -- others $50.00 * 0 LExcisionArthrectomy -- Excision of joint390M Punch biopsy of synovial membrane $79.20 D LTemporomandibular joint391M -- meniscectomy $572.50 42 L392M -- condylectomy $682.70 42 L384M Chemonucleolysis of intervertebral disc $898.80 42 L385M Percutaneous automated discectomy $744.70 42 L398M Excision of neural arch and nerve $1,679.90 42 Lexploration for spondylolisthesisMajor meniscal tears and extensive articulardebridement are each billable.399M Meniscectomy -- knee $578.00 42 L397M meniscus repair includes limited trimming of $774.70 42 LThe fee for open or arthroscopic meniscectomy ormeniscus repair includes limited trimming ofchondromalacia, plica and minor tears of othermeniscus.840M Debridement of Shoulder Joint (Arthroscopic $680.00 42 L-- major debridement should take more than20 minutes. Minor debridement, takingless than 20 min. is included inarthroscopy code 359M)841M Debridement of Knee Joint (Arthroscopic $578.00 42 L-- major debridement should take more than20 minutes. Minor debridement, takingless than 20 min. is included inarthroscopy code 359M)170M Acetabular labral debridement or repair $1,738.00 42 LSynovectomy (not paid in addition to majorjoint surgery)400M -- elbow $950.00 42 L401M -- wrist $900.00 42 LSMA FEE GUIDE -M9 - April 1. 2012

SECTION M:ORTHOPAEDIC SURGERYFeeAnae402M -- finger -- MP joint -- one $700.00 42 L404M -- finger -- IP joint $600.00 42 L406M -- thumb -- MP joint -- one $700.00 42 L407M -- thumb -- IP joint $600.00 42 L408M -- toe -- one $600.00 42 L410M -- hip $879.50 42 L411M -- knee $731.90 42 L412M -- ankle $731.90 42 L413M -- foot $700.00 42 L(Arthrodesis - see page M16) (Excision of ganglion see 671M)ArthroplastyPlastic or reconstructive operation on joint, any type includes reconstructionof ligaments, etc. (Payment for revision of a previous hip arthroplasty, revisionof a total hip replacement or reconstructive arthroplasty and total replacementknee arthropoasty, is made at 150% of the benefit rates of service codes435M, 445M and 444M respectively).The reduction of a dislocated hip within the post-operative period is includedin the payment for the arthroplasty.For a two stage revision of a total hip replacement, the payment is made onthe basis of 435M for the first stage and 885M for the second stage.Synovectomy is an inclusion within the payment for major joint surgery.430M Shoulder $950.00 42 M446M Total $1,655.30 42 M846M Total shoulder replacement -- revision $3,000.00 42 M431M Elbow $950.00 42 L442M Total elbow replacement $1,900.00 42 L842M Total elbow replacement -- revision . $3,800.00 42 L432M Wrist . $1,200.00 42 L448M Total wrist replacement $1,900.00 42 L848M Total wrist replacement -- revision $3,800.00 42 L433M Finger -- one joint $700.00 42 L434M Arthroplasty - finger - one joint - with $492.20 42 Lprosthesis834M Arthroplasty - finger - one joint - with $788.00 42 Lprosthesis -- revision634M -- with extensor tendon transfer $590.00 42 L435M Hip $1,082.80 42 M835M Hip -- revision $2,100.00 42 M445M Total hip replacement or reconstructive $1,655.30 42 Marthroplasty -- revision845M -- with extensive acetabular reconstruction $430.10 42 Mwith bone graft, add885M Total hip replacement or reconstructive $3,000.00 42 Marthroplasty -- revision436M Knee $950.00 42 M444M Total knee arthroplasty includes unicompartmental $1,655.30 42 Mknee and patellar replacement844M Total knee arthroplasty includes unicompartmental $3,000.00 42 Mknee and patellar replacement -- revision437M Ankle $950.00 42 L449M Total ankle replacement -- revision $1,900.00 42 L849M Total ankle replacement -- revision $3,000.00 42 L438M Toe--one joint (except great toe) $700.00 42 L439M Metatarsophalangeal joint -- first -- $387.30 42 Lbunion operation -- unilateralSMA FEE GUIDE -M10 - April 1. 2012

SECTION M:ORTHOPAEDIC SURGERYFeeAnae441M Bunionectomy with metatarsal osteotomy $800.00 42 L-- unilateral460M Hallux rigidus -- repair $800.00 42 LArthrodesis450M Shoulder $2,200.00 42 M451M Elbow $1,500.00 42 L452M Wrist $1,500.00 42 L453M Finger or thumb -- one joint $700.00 42 L853M Arthrodesis - finger or thumb - one joint - $1,837.00 42 Lwith autogenous bone graft (includesharvesting)454M Hip $2,200.00 42 M455M Knee $2,200.00 42 M456M Ankle $1,500.00 42 LTriple arthrodesis464M -- unilateral $1,600.00 42 L467M -- with tendon transplantation, add $600.00 42 LHammer and claw toe -- repair includesexcision, arthrodesis and arthroplastyof IP joints; capsulotomy of MTP joint; alltenotomies, tendon lenghtening and transfers457M -- one toe (except great toe) $350.00 * 42 L459M -- great toe -- interphalangeal joint $700.00 42 L462M Tarsal joints -- one or more $800.00 42 L463M Other joints -- lower extremity $800.00 42 L468M Flat foot plasty or Grice $1,500.00 42 L469M Stabilization of joints by bone block $700.00 42 L470M Sacro-iliac fusion $1,200.00 42 MCapsulorrhaphy -- suture or repair ofjoint capsule and ligamentsShoulder480M -- recurrent dislocation $1,000.00 42 MAcromioclavicular joint489M -- repair $700.00 42 M490M -- reconstruction $1,200.00 42 LKnee Reconstruction370M Knee anterior cruciate ligament-reconstruction, repair or $1,050.00 42 Mreattachment of bony avulsion371M Knee posterior cruciate ligament-reconstruction, repair or $1,050.00 42 Mreattachment of bony avulsion372M Knee posterior cruciate ligament-reconstruction with allograft or $1,576.00 42 Mautograft373M Knee medial collateral ligament-reconstruction with allograft or $1,050.00 42 Mautograft374M Knee medial collateral ligament-repair, reattachment or $700.00 42 Madvancement375M Knee lateral collateral ligament and/or posterolateral corner- $1,800.00 42 Mreconstruction with autograft or allograft376M Knee lateral collateral ligament and/or posterolateral corner- $1,050.00 42 Mrepair, reattachment or advancementAnkle486M -- repair of ligament(s) $436.00 42 L487M -- reconstruction of ligament(s) $850.00 42 LSMA FEE GUIDE -M11 - April 1. 2012

SECTION M:ORTHOPAEDIC SURGERYFeeAnaeHand488M -- reconstruction metacarpophalangeal $700.00 42 Lor interphalangeal ligament(s)500M Manipulation of any peripheral joint $141.20 * 0 Lunder general anaesthesia-- (includes shoulder or hip)Clubfoot520M -- extensive posterior release (includes $2,000.00 42 MAchilles tendon lengthening, flexor hallucislongus lengthening, capsulotomy of theankle and subtalar joints)521M -- complete extensive postero-medial $1,194.10 42 Mrelease (includes code 520M)Club foot -- non operative managementBy reportDislocations1. The fee listed includes:(i) all manipulations to achieve and maintain satisfactoryreduction, and(ii) visits and the reapplication of any casts orfixation media for a related condition on the dateof reduction and during the period prior to thedischarge of hospital in patients.2. Subsequent attempts at reduction are subject to the ruleswithin the preamble to "Fractures".3. Payment for compound dislocations is based on 150%of the fee for closed reduction.4. Only the greater listed amount is paid when afracture and dislocation are billed for the sameday, same site.Temporomandibular530M -- closed reduction with or without $53.30 * 10 LanaesthesiaClavicle-- sternoclavicular537M -- closed reduction $221.50 * 10 L539M -- open reduction $500.00 42 L-- acromioclavicular540M -- closed reduction $221.50 * 42 L541M -- open reduction $572.50 42 LShoulder (humerus)542M -- closed reduction $400.00 * 42 L-- open reduction543M -- fresh $430.10 42 L544M -- old $744.70 42 LElbow545M -- closed reduction $400.00 42 L-- open reduction547M -- fresh $500.00 42 L548M -- old $1,000.00 42 L546M Radial head -- closed reduction $200.00 * 0 L(pulled elbow)SMA FEE GUIDE -M12 - April 1. 2012

SECTION M:ORTHOPAEDIC SURGERYFeeAnaeWrist -- carpal-- one bone549M -- closed reduction $221.50 * 10 L551M -- open reduction $500.00 42 LMetacarpal555M -- closed reduction $129.50 * 10 L557M -- open reduction $600.00 42 LMetacarpophalangeal joint558M -- closed reduction $129.50 * 10 L560M -- open reduction $550.00 42 LInterphalangeal joint561M -- closed reduction $129.50 * 42 L562M -- open reduction $550.00 42 LHip (femur)568M -- closed reduction $500.00 * 42 L569M -- open reduction $1,000.00 42 M570M -- with fracture of posterior portion $1,300.00 42 Mof acetabulum-- congenital -- closed treatment By report573M -- open reduction $1,500.00 42 M574M -- with shelving $1,300.00 42 M575M Pelvic osteotomy -- Salter, etc. $2,200.00 42 M576M -- with arthrotomy $1,310.80 42 MKnee (tibia)577M -- closed reduction $246.10 * 42 L579M -- open reduction $650.00 42 LPatella580M -- closed reduction $221.50 * 10 L582M -- open reduction $313.50 42 LReconstruction for recurrent patellar dislocation583M -- lateral retinacular release $400.00 42 L581M -- soft tissue realignment $1,400.00 42 L589M -- bony realignment including soft $690.00 42 Ltissue realignmentAnkle584M -- closed reduction $400.00 * 42 L585M -- open reduction $650.00 42 L-- subastragalar586M -- closed reduction $400.00 42 L587M -- open reduction $650.00 42 LTarsal588M -- closed reduction $400.00 * 42 L590M -- open reduction $650.00 42 LMetatarsal -- one bone591M -- closed reduction $129.50 * 10 L594M -- open reduction $500.00 42 LToe596M -- closed reduction $79.20 * 10 L598M -- open reduction $500.00 * 42 LBursae610M Incision & drainage of infected bursa $59.80 * 10 LSMA FEE GUIDE -M13 - April 1. 2012

SECTION M:ORTHOPAEDIC SURGERYFeeAnae611M Removal of subdeltoid calcareous deposits $313.50 42 L612M Removal of subtrochanteric calcareous $313.50 42 LdepositsRemoval of calcareous deposits -- other joints -- see Arthrotomy614M Puncture for aspiration or needling with or $31.00 * 0 Lwithout irrigation or injection of medication620M Radical excision of bursae -- forearm, viz. $541.40 42 Ltenosynovitis, fungosa, Tbc., and othergranulomasExcision of bursa621M -- olecranon $500.00 * 42 L622M -- prepatellar $500.00 * 42 L623M -- subacromial $350.00 42 L624M -- ischial $430.10 42 LMuscles630M Quadriceps plasty $900.00 42 L631M Repair of ruptured limb muscle -- belly, $387.30 42 Lorigin, or insertion(for lacerations -- see 890L, 896L)Tendons, Tendon Sheaths and FasciaIncisionDrainage of tendon sheath640M -- one digit $400.00 * 42 L641M -- single palm and/or wrist, ulnar or $500.00 42 Lradial bursa -- in hospital642M Injection of tendon sheath $57.20 * 0 L643M Incision of fibrous sheath of tendon for $500.00 42 Lstenosing tenosynovitis644M Division of iliotibial band -- open $320.00 42 LreductionOber and Yount fasciotomy, combine (orSoutter procedure) with spica cast, pinsin tibia, wedging of casts, etc.645M -- unilateral $1,660.00 42 L646M Compartment Pressure Monitoring $154.10 D LHip adductors-- unilateral649M -- percutaneous $300.00 42 L650M -- open $750.00 42 L-- bilateral651M -- percutaneous $400.00 42 L652M -- open $900.00 42 L-- with peripheral obturator neurectomy653M -- unilateral $302.00 42 LIntrapelvic obturator neurectomy655M -- unilateral $354.00 42 M657M Sever (or similar procedure) of shoulder $1,600.00 42 Lfor Erb's palsyExcision671M Excision of lesion of tendon or fibrous $500.00 * 42 Lsheath, or ganglionRadical excision of bursae, forearm, viz.tenosynovitis, fungosa, Tbc., and othergranulomas -- See 620MSMA FEE GUIDE -M14 - April 1. 2012

SECTION M:ORTHOPAEDIC SURGERYFeeAnae673M Excision of Baker's cyst $600.00 42 L674M Fasciotomy -- single -- palm or sole -- $400.00 42 Lsubcutaneous -- blindFasciectomy -- open -- plantar677M -- unilateral $700.00 42 L678M Compartment syndrome release -- for trauma $744.70 42 LRepair680M Tendon sheath reconstruction -- $650.00 42 Linsertion of silastic rod681M -- each additional $357.40 42 L780M Repair boutonniere deformity $393.80 42 LRepair or suture -- extensor tendon690M -- single hand or foot -- distal to wrist $550.00 * 42 Lor ankle-- each additional tendon691M -- foot $300.00 * 42 L692M -- hand $550.00 * 42 L693M -- single -- forearm or leg $500.00 * 42 L-- each additional tendon694M -- leg $55.00 * 42 L695M -- forearm $500.00 * 42 LRepair or suture -- flexor tendon696M -- single unless otherwise listed $800.00 42 L697M -- each additional $600.00 * 42 LTransfer or transplant of tendon -- single698M -- distal to elbow, distal to knee $850.00 42 L700M -- each additional $700.00 42 L701M -- elbow or shoulder, knee or hip $850.00 42 L702M -- each additional $300.00 42 L781M Free extensor tendon graft -- single $600.00 42 L782M -- each additional $410.00 42 L703M Free flexor tendon graft -- single $1,050.00 42 L704M -- each additional $1,033.60 42 LTenolysis705M -- single -- flexor $700.00 42 L706M -- each additional $450.00 42 L725M -- single -- extensor $500.00 42 L726M -- each additional $400.00 42 L727M Tenodesis $850.00 * 42 L707M Lengthening or shortening tendon $600.00 42 L708M Opponens transfer $800.00 42 L709M Intrinsic transplant active or passive $603.50 42 L710M Intrinsic release (Littler) or incision $500.00 42 L711M -- additional fingers $300.00 42 L712M Free fascial graft for reconstruction $600.00 42 Ltendon pulley or repair bowstring tendon-- single714M Abdominal fascial transplants -- bilateral $639.90 42 L716M Ruptured quadriceps tendon - repair $700.00 42 L481M Raptured patellar ligament - repair $700.00 42 L721M Ruptured patellar ligament or Achilles $850.00 42 Ltendon -- repair with fascial or tendon graft717M Ruptured biceps tendon - elbow - repair $700.00 42 L718M Flexor-plasty -- elbow $700.00 42 L719M Repair ruptured supraspinatus tendon or $950.00 42 MSMA FEE GUIDE -M15 - April 1. 2012

SECTION M:ORTHOPAEDIC SURGERYmusculotendinous shoulder cuff -- withor without acromioplastyFeeAnaeTenotomy722M -- percutaneous $500.00 * 10 L723M -- open $500.00 * 10 L724M -- each additional (of either 722M or 723M) $300.00 * 10 LExtremitiesIncision731M Drainage of single infected space of hand $700.00 42 L(lumbrical, hypothenar, thenar, middlepalmar, etc.) with or without tendonsheath involvement732M Drainage of multiple infected spaces of $1,100.00 42 Lhand with or without tendon sheathinvolvementAmputationUpper Extremity740M Interthoracoscapular $1,500.00 42 M741M Disarticulation of shoulder $1,500.00 42 M742M Arm through humerus $1,500.00 42 M743M Forearm, through radius and ulna $1,500.00 42 M745M -- with subsequent revision or $1,500.00 42 Mreamputation746M Cineplasty -- complete procedure $1,253.00 42 M747M Disarticulation of wrist $1,500.00 42 M748M Hand, through metacarpal bones $1,500.00 42 M749M Metacarpal, with finger or thumb, one with $1,500.00 42 Lsplit or Wolff graft, or skin-plasty and/ortenodesis with definitive resection palmardigital nerves750M Finger, any joint, or phalanx, one -- with $800.00 * 10 Lsplit or Wolff graft, or skin-plasty and/ortenodesis, with definitive resection volardigital nervesLower Extremity760M Interpelviabdominal $1,365.30 42 H761M Disarticulation of hip $1,900.00 42 M762M Disarticulation of knee $1,156.00 42 M763M Thigh through femur, including supracondylar $1,176.00 42 M765M -- Revision or reamputation $256.00 42 M766M Leg, through tibia and fibula $1,500.00 42 M768M -- Revision or reamputation $260.00 42 M769M Ankle (Syme, Pirogoff) -- with skin-plasty $1,500.00 42 Mand resection nerves770M Foot -- transmetatarsal $1,500.00 42 M771M Midtarsal $1,500.00 42 M772M Metatarsal, with toe, split or Wolff graft $800.00 42 Lor skin-plasty and/or tenodesis, withdefinitive resection digital nerves774M Toe, any joint or phalanx, one -- with split $600.00 * 10 Lor Wolff graft, or skin-plasty and/ortenodesis, with definitive resectiondigital nervesSMA FEE GUIDE -M16 - April 1. 2012

SECTION M:ORTHOPAEDIC SURGERYPlaster CastsService codes 800M to 822M are payable in conjunctionwith a consultation, complete assessment or initialassessment service when the physician personallythe casts.Payment may be made for the reapplication of caststhe day of surgery.Finger or Toe -- bill as a visit feeFeeAnaePlaster Casts800M -- forearm $91.40 * 0801M -- elbow to fingers $91.40 * 0802M -- hand or wrist $90.00 * 0803M -- shoulder to hand $100.00 * 0804M -- shoulder spica $100.00 * 0805M -- ankle (foot to midleg) $100.00 * 0806M -- knee (foot to thigh) $112.00 * 0808M Ambulatory leg cast $100.00 * 0809M Molded plaster to leg $150.00 * 0Spica810M -- unilateral (rib margin to toe) $1,050.00 * 0Body812M -- shoulder to hip $500.00 * 0813M -- including head $160.50 * 0814M Unna boot $102.00 * 0815M Wedging of cast $100.00 * 0820M Risser, or similar, cast for scoliosis $1,050.00 0821M Halo cast $406.60 42822M Application of hinged brace on knee cast $154.10 * 0-- composite fee for brace and cast825M Cast removal (when physician personally $30.00 * 0removes the cast)SMA FEE GUIDE -M17 - April 1. 2012

SECTION N:PLASTIC SURGERY2. Correction of functionally disabling or disfiguring abnormalities of deepstructures due to disease, trauma or congenital defect is insured.Repair of traumatic or disease induced hair loss is insured. Medical or3. surgical therapy for familial hair loss is uninsured.4. Correction of facial or neck deformity due to aging is uninsured.5. Blepharoplasty of upper eyelids is insured if there is obstruction of thevisual axis and/or lash inversion with ocular irritation.Blepharoplasty of the lower eyelids is insured only when the deformityresults in exophthalmos, ectropion, or interferes with wearing eyeglasses.When one eyelid is altered due to the above, trauma, or ablative cancersurgery then a contralateral balancing procedure is insured.Fee for correction of blepharoptosis includes associated blepharoplasty.6. Repair of protruding or congenitally deformed ears is insured under theage of 18. For those 18 and over, repair is insured under exceptionalcircumstances such as early unwarranted parental opposition,unavailability of service, financial limitations, etc.7. Rhinoplasty is insured if the nasal malformation is due to trauma,disease, neoplasm, or birth defect.Rhinoplasty to alter appearance due to a familial trait or aging is uninsured.Rhinoplasty for appearance, when done with a septoplasty, is uninsuredand the costs of the former are the responsibility of the patient.8. Ablation of facial or neck port-wine stain by dye tuned laser is insuredunder the age of 18. Pre-authorization required for other symptomaticor bleeding cutaneous angiomata or for individuals over the age of 18.Other Body Areas1. Scar revision is insured if scars cause a functional disability, are painful,are unstable, or if revision is part of a pre-planned staged reconstructiveprocedure.Scar revision is also insured if there is a history of post-operativecomplication or condition affecting wound healing.2. Tattoo ablation or excision is insured only if it has been placed involuntarily.Otherwise, cost of removal is the responsibility of the patient.3. Augmentation mammoplasty is insured for congenital or post-surgicalamastia. If unilateral augmentation mammoplasty is done for the abovereasons, then a balancing operation such as augmentation, reduction,or mastopexy is insured for the opposite breast.Augmentation mammoplasty may be insured for a severelyhypoplastic breast where the second breast is not hypoplastic,subject to prior approval by MSB Medical Consultant(s).4. Reduction mammoplasty is insured if, due to the size of the breast,there are symptoms such as, painful shoulder grooves, intertrigo, breastpain, backache, or significant posture changes.Reduction mammoplasty is insured if there is significant sizediscrepancy between the breasts.SMA FEE GUIDE - N2 - April 1, 2012

SECTION N:PLASTIC SURGERY5. Abdominoplasty is insured if an apron persists following weight loss tonormal levels after treatment of morbid obesity by gastroplasty,intestinal bypass surgery, or strict dietary control.Abdominoplasty is also insured when the apron causes back pain,intertrigo, problems with locomotion, or significant posture changes.Abdominoplasty is also insured when the abdominal wall musculaturehas been significantly comprised following surgery, trauma, or obstetricalcomplication.Panniculectomy (removal of fat only) is insured only in the abovecircumstances and when the abdominal musculature is not altered.6. Non-abdominal lipectomy (batwing deformity of arms and thighs) isinsured under the same criteria set down for abdominoplasty.7. Spider vein (telangiectasia) treatment by injection, excision, thermalablation, or laser therapy is not insured. Treatment of symptomaticvaricose veins is insured.8. Sex reassignment surgery is insured only if performed on patients whohave currently completed the Gender Identity Clinic program of theClarke Institute and for whom surgery has been recommended.Procedures Fee AnaeAdditional payments for diagnostic serviceexcluding ECG's, 0, 10 or 42 day operativeprocedures performed on patients under one (1) yearof age are automatically calculated and paidas explained in Section A, pages A34 and A35.32N Removal of interdental and/or intermaxillary $81.30 * 0 Lwiring and/or arch barGRAFTS -- Multiple areas -- service codes 228Nto 244N plus 280N are eligible for payment at100% of the listed payment when performed ondifferent areas.Transplantation of SkinNon-functional Area229N Split graft to cover minimal open area up $125.00 * 10 Lto defect of 6 square cm. (exception face)230N Defects up to 65 square cm. onlay -- $232.00 42 Lmeticulous operative fixation not required231N Defects up to 194 square cm. (trunk, $460.00 42 Larms, legs) onlay type of graft --meticulous fixation not required232N Defects of a sectional nature (thighs, $621.70 42 Llower leg, forearm) onlay type of graft --meticulous fixation not required233N -- multiple defects as in severe burns, onlay $904.20 42 Mtype of graft, donor site (usually completecircumference of one limb or minimum ofthree drums of skin)Defects (trunk, arms, legs) -- resection oftissue, meticulous suture technique,multiple tie overs and other fixation228N -- less than 26 square cm. $524.30 10 L234N -- 26 to 103 square cm. $1,058.20 42 L235N -- more than 103 square cm. $879.50 42 MSMA FEE GUIDE - N3 - April 1, 2012

SECTION N:PLASTIC SURGERYFeeAnaeFunctional Areas236N Finger -- split graft of skin -- plasty $600.00 42 L237N Regions of major joints, hands, feet or $608.80 42 Lneck (early)238N Regions of major joints, hands, feet or $1,065.70 42 Mneck (late with excision of scar and skingraft)239N Regions of major joints, hands, feet or $676.20 42 Lneck (late where excision of scar is lessthan entire dorsum of hand, i.e., threefingers and a portion of dorsum, or, oneside of neck)269N Mesh grafting -- paid in addition to split $202.00 42 Lthickness grafts when 2 or more carriersare meshedFree Graft -- Full Thickness - Facial241N Eyelids, canthi, alae of nose and ears $608.80 42 LFree Graft -- Full Thickness - Other242N -- less than 5 square cm. $600.00 10 L243N -- over 5 square cm. and up to $750.00 42 L10 square cm.244N -- more than 10 square cm. $900.00 42 L280N Composite graft (full thickness of external $639.90 42 Lear)Cavity Grafting245N Eye socket -- reconstruction $879.50 42 M247N Oral -- buccal inlay $751.10 42 M248N Bone cavity $682.70 42 L249N Vagina -- with reconstruction for $812.10 42 Lcongenital absenceFlaps or Tubes of Skin from a DistanceMajor stage(s)252N -- raising of large direct flap or tube $639.90 42 Lpedicle with closure of donor area253N -- raising of large direct flap or tube $892.40 42 Lpedicle and skin graft to donor areaMinor stage(s) -- transposition of pedicle254N -- intermediate transfer or sectioning $430.10 42 Lof pedicle with direct closure255N -- delay of pedicle $500.00 42 L256N Muscle flap with skin graft $2,600.00 42 M257N Myo-cutaneous flaps with donor closure $2,400.00 42 M258N Myo-cutaneous flaps with skin grafts to $1,900.00 42 Mdonor areaFascio-cutaneous flap -- greater than 19 sq. cm.250N -- with donor closure $2,000.00 42 M251N -- with skin graft to donor area $2,400.00 42 M361N Neurovascular pedicle flap $817.50 42 M440N Transverse rectus abdominis myocutaneous $2,400.00 42 Mflap for breast reconstructionExcision and/or Repair by AdjacentTissue Transfer or Rearrangementi.e., Z-plasty, rotation flap, advanced flap,double pedicle flap, etc.Defect up to 6 square cm.260N -- trunk $350.00 42 LSMA FEE GUIDE - N4 - April 1, 2012

SECTION N:PLASTIC SURGERYFeeAnae261N -- scalp, arms and legs $406.60 42 L262N -- forehead, cheeks, chin, mouth, $500.00 42 Lneck, axilla, genitalia, feet or hands263N -- eyelids, nose, ears and lips $608.80 42 LDefect 7-19 square cm.264N -- trunk $500.00 42 L265N -- scalp, arms and legs $550.00 42 L266N -- forehead, cheeks, chin, mouth, $700.00 42 Lneck, axilla, genitalia, hands or feet267N -- eyelids, ears, nose and lips $750.00 42 L268N More than 19 square cm. -- unusual or $1,000.00 42 Lcomplicated, by reportSyndactly371N -- release with flaps $650.00 42 L372N -- release with flaps and skin grafts $1,000.00 42 LLymphoedema excisionMinor excision -- use codes 260N - 268N659N -- major excision and grafting By Report 42 MEyelids -- full thicknessExcision and RepairBy advancement flaps270N -- up to 1/4 of eyelid margin $528.60 42 L271N -- over 1/4 of eyelid margin $621.70 42 LBy transfer flaps of tarso conjunctiva fromopposing eyelid272N -- up to 2/3 of eyelid $621.70 42 L-- total eyelid 1 or more stages273N -- lower lid $843.20 42 L274N -- upper lid $953.40 42 LBlepharoplasty with repair of orbitalseptal hernia -- unilateral276N -- upper lid $725.50 42 L277N -- lower lid $756.50 42 LTransplantation of Tissues Other than Skin281N Mucous membrane graft $356.00 42 L283N Fascia grafts for facial nerve paralysis $900.00 42 L285N Slings for ptosis $738.30 42 L286N Cartilage -- autogenous transplant $843.20 42 LBone -- autogenous transplant287N -- nose, chin, orbit, forehead $1,261.50 42 MAbrasive SurgeryFacial resurfacing - total face for removalof scars, etc.290N mechanical -- primary $751.10 42 L291N mechanical -- secondary $344.50 42 L492N laser - laser owned by physician $104.00 * 10 L-- first 15 minute session493N laser - each subsequent 15 minutes to a $51.80 * 10 Lmaximum of 10Regional -- cheeks, chin, forehead orelsewhere (any method including laser)292N -- primary $196.90 42 L293N -- secondary $93.10 42 LSMA FEE GUIDE - N5 - April 1, 2012

SECTION N:PLASTIC SURGERYFeeAnaeNose300N Rhinoplasty . $1,033.60 42 M301N Rhinoplasty with Septoplasty or $1,230.50 42 MSubmucous Resection302N Rhinophyma -- removal by shaving $566.00 42 L303N Silastic implant -- when only procedure $461.20 42 L304N Segmental nasal resection -- when only $295.30 42 Lprocedure305N Bone graft with 300N and 301N -- add $455.80 42 LEar310N Preauricular fistula $387.30 42 LProtruding ears -- otoplasty311N -- unilateral $572.50 42 L313N Segmental ear resection $344.50 42 LCleft Lip and Cleft PalatePlastic repair of cleft lip, primary320N -- unilateral $1,500.00 42 M323N Plastic repair of cleft lip, secondary, by $1,200.00 42 Mrecreation of defect and closure324N Repair of cleft lip by Abbe flap in two $1,009.00 42 Mstages325N Repair of nasal deformity due to cleft lip $966.20 42 MPlastic operation for cleft palate326N -- partial -- primary $1,500.00 42 M327N -- complete -- primary $1,800.00 42 M328N -- major revision -- secondary $1,500.00 42 M329N Palate -- pharyngo-plasty $1,400.00 42 MLips, Cheeks and Jaws330N Vermilionectomy or gingivectomy $550.00 42 L331N Transverse wedge excision, lip $400.00 42 L631N Rectangular or square through and through $700.00 42 Lresection of the lower lip332N Radical resection of lip -- 1/2 or more with $953.40 42 Mprimary reconstruction333N Total reconstruction of lip $1,335.40 42 MMandibular prognathism and micrognathismRepair in one or two stages,334N -- excluding interdental wiring $1,335.40 42 M335N -- including interdental and $1,612.00 42 Mintermaxillary wiring634N LeFort I osteotomy of maxilla $2,313.30 42 M635N -- with bone grafting $2,590.50 42 MExcision of cyst of dental origin -- intraoralapproach336N -- under 1 cm. $93.10 42 M337N -- 1-2.5 cm. $236.00 42 M338N -- over 2.5 cm. $566.00 42 M339N Interposed bone-graft augmentation of $1,394.00 42 Matrophic mandibleFractures of the Facial BonesNose340N -- intranasal reduction and splinting $500.00 42 M341N -- total refracture and fixation $528.60 42 MMandible342N -- interdental wiring (horizontal) $500.00 42 M343N -- intermaxillary wiring including interdental wiring $1,200.00 42 MSMA FEE GUIDE - N6 - April 1, 2012

SECTION N:PLASTIC SURGERYFeeAnae344N -- open reduction of single fracture, $800.00 42 Mexcluding interdental or intermaxillarywiring345N -- multiple compound or comminuted fractures $1,200.00 42 Mexcluding interdental or intermaxillarywiringMaxilla346N -- displaced -- open reduction $1,200.00 42 M347N -- open reduction with antrostomy $812.10 42 M(Caldwell Luc and packing)348N Malar bone and zygomatic arch open $800.00 42 Melevation or temporal approach (Gillies)349N Complete facial smash with cranial facial By Reportseparation, complicated, open reduction,multiple surgical approaches, internalfixation, wiring teeth, etc.TrunkMammaplasty reduction350N -- unilateral $1,494.80 42 MSubcutaneous mastectomy for fibrocystic diseaseand immediate insertion of mammary prosthesis-- unilateral390N -- one surgeon $879.50 42 L391N -- two surgeons, each $430.10 42 LBreast augmentation -- prosthetic352N -- unilateral $738.30 42 LSubcutaneous tissue space expander400N -- implantation $950.00 42 L401N -- removal (including replacement by $950.00 42 Lprosthesis)430N Nipple reconstruction, post mastectomy $700.00 42 L431N Repair of inverted nipple $350.00 42 L432N Removal of single breast prosthesis $200.00 42 L433N Removal of single breast prosthesis with $676.20 42 Lcapsulectomy and/or skin plasty354N Abdominoplasty including lipectomy $1,400.00 42 LPost-gastroplasty redundant skin fold removal654N -- bat wing, unilateral $498.60 42 L655N -- thigh, unilateral $498.60 42 L355N Decubitus ulcer -- repair by excision of $1,800.00 42 Mbursa and underlying bone with rotationflap -- total careHypospadias356N -- first stage repair $714.00 42 L357N -- second stage (urethroplasty) $1,018.00 42 L657N Single stage hypospadius repair $2,038.00 42 L358N -- urethral fistula repair $313.50 42 L359N Epispadias $812.10 42 L360N Removal of axillary sweat glands $621.70 42 L(unilateral)Extremities362N Phalangization $639.90 42 L363N Pollicization $1,230.50 42 M364N Cross finger flap -- total care $958.70 42 L365N Transposition of digit $958.70 42 LSMA FEE GUIDE - N7 - April 1, 2012

SECTION N:PLASTIC SURGERYFeeAnae367N Palmar fasciectomy for Dupuytren's $1,100.00 42 Lcontracture -- primary368N Dupuytren's contracture - recurrent $1,300.00 42 LThumb - M.C.P. joint - collateral ligamentreconstruction369N -- by local tissue rearrangement $449.40 42 L370N -- using tendon graft $676.20 42 LSkinExcision of LesionsBenign-- non-facial (see Section L)380N -- facial on referral $190.00 10 LMalignant -- by wide excision and suture684N -- non-facial $300.00 10 L685N -- facial (not including neck and scalp) $400.00 10 LExcision of malignant skin lesions with skin graftor flap repair - (use appropriate codes)Wounds -- face -- single or multiple -- onreferral to a plastic surgeon-- plastic repair382N -- up to 5 cm. $350.00 10 L383N -- each additional 2.5 cm. $200.00 10 LWound Management420N Vacuum assisted wound management, By Report Lsetup (indicate start time, stop time andsize of wound on claim submission)421N Vacuum assisted wound management, $150.00follow-up (includes visit)(complicated cases may be billed by report)BurnsInitial management of severe burns -- bill under918A according to time.453N Subsequent dressings for severe burn $57.80 * 0patients per 5 % body surface area -- performedby the physician without anaesthesiaSpray or topical anaesthetic agents do not qualifyas anaesthesia under these codes.454N -- with general anaesthesia $67.40 * 0 LDebridement of burns without anaesthesia isincluded in the visit or dressing fee.455N Surgical debridement of burns under $89.90 * 0 Lgeneral anaesthesia including dressings-- initial 5% of body surface area456N -- each additional 5% or major part $67.40 * 0 Lthereof, addTangential excision460N -- single hand $270.70 42 L461N -- single foot $178.70 42 LSMA FEE GUIDE - N8 - April 1, 2012

SECTION N:PLASTIC SURGERYFeeAnaeEscharotomy470N -- hand $369.20 42 L471N -- foot $313.50 42 L472N -- arm, forearm, thigh, leg or trunk $276.10 42 LMicrovascular Surgery500N Preparation and harvesting of graft and $1,700.00 42 Hclosure of donor site501N Preparation of distant recipient site $1,700.00 42 Hincluding repair of nerves, tendons,bones and skin502N Preparation of adjacent donor and $2,200.00 42 Hrecipient sites including repair of nerves,tendons, bones and skin .Revascularization503N -- arterial $1,200.00 42 H504N -- with vein graft $1,400.00 42 H505N -- venous $1,200.00 42 H506N -- with graft . $1,400.00 42 HAssessment Rules for Microvascular Surgery1. Codes apply only when provided by a recognized microvascular surgical unit.2. Codes represent composite payments for all related microvascular surgicalservices provided at time of surgery, i.e. no codes outside the group(500N - 506N) are payable.3. Each individual code is billable only once per anatomical site.4. Normal surgical rules do not apply for the following:(a) if multiple sites, payment is at 100% per site;(b) combination of discrete codes within the group (500N - 506N) are payable at 100%;(c) if initial vascularization fails and a second attempt is necessary, no paymentwill be made for the repeat procedure.5. The 75% rule would apply for amputation where all attempts torevascularize fail.6. Code 502N is not payable with 500N or 501N.7. 503N and 504N are not payable together.505N and 506N are not payable together.8. All Claims will be assessed by a Medical Consultant.Under this arrangement the maximum payable site would be $4,200.00.SMA FEE GUIDE - N9 - April 1, 2012

SECTION O:PHYSICAL MEDICINEVisitsFee3O Complete assessment $180.00-- includes: pertinent family history, patienthistory, history of presenting complaint,functional enquiry, examination of all partsand systems, diagnosis,assessment,necessary treatment, advice to the patientand record of service provided5O Partial assessment or subsequent visit $154.00-- includes: history review, history of presentingcomplaint, functional enquiry, examination ofaffected part(s), diagnosis, assessment,necessary treatment, advice tothe patient and record of service provided9O Consultation $374.00-- includes all visits necessary, history andexamination, review of laboratory and/orother data and written submission of theconsultant's opinion and recommendationsto the referring doctor11O -- repeat $210.0014O Hospital Inpatient Consultation -- includes all visits $532.00necessary, history and examination, review oflaboratory and/or other data and writtensubmission of the consultant's opinion andrecommendations to the referring doctorHospital Care*(*Payable on day of admission)25O -- first 10 days, per day $49.60 *26O -- 11-20 days, per day $44.00 *27O -- 21-30 days, per day $20.00 *28O -- thereafter, per day $20.00 *Note: for hospital discharge by physician,see code 725A, in Section ACase ConferenceMust be a formal scheduled session. A singleconference fee billed in the name of one patientcovers all the patients reviewed at the conference. Amaximum of six case conferences per patient peryear is billable. The physician should keepappropriate documentation of time and place.42O per conference (not patient) -- first 30 minutes or part thereof $140.0044O - add to 42O for each additional 15 minutes or part thereof $70.00SMA FEE GUIDE - O1 - April 1. 2012

SECTION P:OBSTETRICS/GYNAECOLOGYVisitsFee5P Initial Assessment $106.00-- of a specific condition includes:pertinent family history, patienthistory, history of presentingcomplaint, functional enquiry,examination of affected part(s) orsystem(s), diagnosis,assessment,necessary treatment, advice to the patientand record of service provided7P Follow-up Assessment $61.00 *-- includes: history review, functionalenquiry, examination, reassessment,necessary treatment, advice to the patientand record of service provided9P Consultation $164.00-- includes all visits necessary, historyand examination, review of laboratoryand/or other data and writtensubmission of the consultant'sopinion and recommendationsto the referring doctor11P -- repeat $80.80Hospital Care(Payable on day of admission)25P -- first 10 days, per day $51.40 *26P -- 11 -20 days, per day $51.40 *27P -- 21-30 days, per day $23.40 *28P -- thereafter, per day $23.40 *Note: for hospital discharge by physician,see code 725A, page A288P Pre-natal visit subsequent to a first visit $61.00under 5P for maternity care or post-nataloffice visit13P Interpretation of telephonic foetal $72.80monitoring by consultant with immediateresponse, per patientObstetrics1. Payment for prenatal and postnatal office visits is made on a "fee-for-service"basis.2. If during the course of labour, the attending physician callsa consultant to deliver his patient because complications havearisen, payment may be made:(a) to the consultant for the consultation and delivery, and(b) to the referring physician for the pre-natal care he hasprovided plus 42P.Note: A 42P is not paid when one general practitioner refers a patient toanother general practitioner in the same clinic or vaginal delivery.However in the situation where no consultant obstetrician isavailable and the general practitioner is acknowledged to havespecial training and/or skills in obstetrics, it can be paid on report.SMA FEE GUIDE - P1 - April 1, 2012

SECTION P:OBSTETRICS/GYNAECOLOGYAlso if during the course of labour the attending physician has tocall another physician who may be a general practitioner in the sameclinic to deliver his patient by caesarian section because the referringphysician does not have surgical privileges, then he may bill undercode 42P. He will also be paid for surgical assistant services atcaesarian section if provided.3. When the patient is referred for a caesarian section the surgeon isresponsible for post-operative care.4. Payment for "vaginal delivery" includes the following services by thesame physician, a general practitioner in the same clinic, or aspecialist in the same speciality and clinic:(a) medical and surgical induction except for code 47P;(b) the treatment of false labour and primary uterine inertia duringthe two days prior to delivery;(c) the management of labour; no visit service or hospital care ispayable for a patient in normal labour. This is included in the compositevaginal delivery fee.(d) hypnotherapy;(e) vaginal delivery (including version--internal or external, use of forcepsrepair of lacerated cervix, repair of vaginal and first and second degreeperineal lacerations and /or pudendal block or other infiltration orregional anaeasthesia, repair of episiotomy);(f) services for the control of haemorrage within 24 hours of delivery;(g) visit (including hospital care) or consultation services during thepatient's stay in hospital following delivery.5. Out of hours service premiums in Section A.6. To support and encourage family physicians to remain or becomeinvolved in obstetrics, a bonus of 25% will be paid in each fiscal(beginning April 1 of each year) on the first 25 Vaginal Delivery (41P)or Continuing Care at Delivery (42P) services provided by a familyphysician. The bonus will be paid automatically in a claim runfollowing the end of each quarter as an adjustment to 41P or 42P.Physicians are encouraged to submit claims for 41P and 42P in atimely manner to ensure that they receive the bonus payment towhich they are entitled.Fee42P Continuing care provided by the attending $1,160.00 *physician during the course of labour priorto calling a consultant to deliver the patientand including post-natal care in hospital whenprovided.This service code is applicable onlyif during the course of labour and after asubstantial amount of time has lapsed becauseof complications, e.g., foetal distress,failure to progress, the attending physicianfinds it necessary to call a consultant todeliver the patient; please indicate on theclaim the name of the consultant to whom thecase was referredVaginal delivery and post-natal care inhospital40P -- specialist $1,160.0041P -- general practitioner $1,160.00241P Delivery of stillborn (claim only where a $1,158.00 *foetus was a minimum of 500 gramsand/or had reached 20 weeks gestation)Multiple pregnancy44P -- each additional child $280.00 *SMA FEE GUIDE - P2 - April 1, 2012

SECTION P:OBSTETRICS/GYNAECOLOGYFeeAnae45P Intrauterine manual separation and removal $227.90 * 0 Mof retained placentaCaesarian section^46P -- any type and post-operative care $1,218.00 * M246P -- intrapartum, add $180.00 *47P Chemical induction or augmentation of $72.40 *labour -- payable once per delivery, add48P Ectopic gestation -- removal $980.00 * 42 M248P Ectopic gestation salpingotomy, embryectomy $1,050.00 42 Mand salpingorraphy49P Occlusive suture of cervix in pregnancy $400.00 10 MRemoval of occlusive suture of cervix269P -- office procedure $35.80 * 0279P -- hospital procedure under anaesthesia $200.00 * 0 L^ Tubal resection and/or ligation performed forsterilization at the time of Caesarian Section ispayable under Code 135P at 75%Complications of PregnancyTwo of these codes may be paid per patient per pregnancyto one or two physicians. If a third or subsequent code isrequested, there should be an accompanying explanation.200P Breech presentation -- delivered $220.00vaginally, add201P Face or brow presentation -- delivered $165.90vaginally, add202P Transverse or occiput posterior -- forceps $178.70extraction or vacuum extraction (excludesoutlet or elective forceps), add203P Prolonged rupture of membranes for $178.70over 24 hours, add204P Abruptio placenta, add $178.70205P Placenta previa, add $178.70206P Vaginal delivery following previous $200.00caesarian section, add207P Pregnancy - severe hypertension requiring $221.50pharmacological therapy and monitoring, add208P Pharmacological suppression of premature $178.70labour, add209P Repair of significant cervical $203.30laceration, add210P Previous stillbirth after 20 weeks, add $178.70211P Cephalic version under ultrasound control $178.70with or without tocolysis add212P Cephalic version under ultrasound control $203.30with tocolysis, add213P Diabetes requiring insulin antepartum, add $178.70214P IUGR (birth weight < 5th percentile), add $178.70215P Pregnancy and heart disease (New York $178.70Heart Association Class 3 or 4), add216P Pregnancy and pre-existing hypertension $178.70(on antipypertensive therapy beforepregnancy), add217P Pregnancy and anitphospholipid antibody $178.70syndrome, add218P Pregnancy and significant medical disease $178.70(Not listed above) requiring active concurrentmanagementSMA FEE GUIDE - P3 - April 1, 2012

SECTION P:OBSTETRICS/GYNAECOLOGYFeeAnaeTherapeutic abortion (includes incomplete andmissed abortion)50P -- first trimester $387.30 * 42 L250P -- second trimester $528.60 42 L350P -- D&C for incomplete or missed abortion $387.30 * 42 L51P Intrauterine foetal transfusion $608.80 1052P Repair of fourth degree tear following $380.90 42 Ldelivery54P Repair of 3rd degree tear following $190.50 10 Ldelivery or secondary repair ofepisiotomyNote: Repair of episiotomy is included in thedelivery fee.53P Replacement of inverted uterus $380.90 42 L55P Insertion of intrauterine pressure $57.20 * Dcatheter56P Application of scalp electrodes for internal $59.30foetal EKG monitoring258P Transvaginal fetal scalp blood sampling $124.00 * D(payable twice per pregnancy)Amniotic tap -- trans-abdominal57P -- second trimester $167.00 * D58P -- third trimester $121.00 * D59P Fetoscopy -- including fetal blood sample, $319.90 Dcell harvest or amniocentesisNon stress test -- in office (if equipmentowned by physician)260P -- First foetus $71.80 D261P -- Second and subsequent, per foetus add $54.00 DProceduresAdditional payments for diagnostic serviceexcluding ECG's, 0, 10 or 42 day operativeprocedures performed on patients under one (1) yearof age are automatically calculated and paid asexplained in Section A, pages A34 and A35.Gynaecology30P Vaginal sperm examination $79.20 * DIn vitro sperm penetration test330P -- technical component $53.50 * D331P -- professional component $53.50 * D338P Sperm washing prior to insemination $79.20 * 0(performed in physician's own office)31P Tubal insufflation or hysterosalpingogram or $105.90 * D Lsonohysterogram -- Rubins (bilateral)32P Pelvic examination under anaesthesia $130.00 * D L(when only procedure done)33P Culdocentesis (when only procedure done) $64.20 * D L34P Culdoscopy or laparoscopy $387.30 D M(laparoscopy not paid with laparoscopicsurgery unless it precedes the surgery as adiagnostic procedure) -- with or without biopsySMA FEE GUIDE - P4 - April 1, 2012

SECTION P:OBSTETRICS/GYNAECOLOGYFeeAnae35P -- with division of adhesions or cautery $482.00 10 Mfor endometriosis with or withoutperitoneal lavage334P Hysteroscopy, with or without D & C, with $246.10 D Lor without other intrauterine procedures335P Endometrial ablation, to include excision $674.00 42 Mof endometrial polyps and/or fibroids336P Excision of endometrial polyps and/or $135.00 * 42 Lfibroids -- add to 334P or 335P only232P Hysteroscopic division of uterine septum $568.00 42 L233P Fallopian tube cannulation by hysteroscopy, $505.00 42 Lunilateral or bilateral36P Hydrotubation $93.10 * 0 L37P Colposcopy -- not in office $119.80 * D L38P -- with biopsy -- not in office $154.10 * D L438P Colposcopy - in office $76.60 * D439P -- with biopsy - in office $89.20 * D39P Endometrial tissue biopsy by aspiration $105.90 * D LMenopausal gonadotropin therapy -- add toappropriate visit fee314P -- initial set-up per treatment cycle $152.00315P -- subsequent injections, add to $50.60appropriate visit fee .VulvaVenereal warts -- see 420R, 421R, 422R60P Hymenectomy $227.90 * 0 L(in hospital -- general anaesthetic)Bartholin cyst61P -- incision $79.20 * 10 L78P -- marsupialization $227.90 * 42 L62P -- excision $301.70 * 42 L63P Skene's glands -- cautery or excision $105.00 * 10 LUrethra -- caruncle65P -- cautery $233.30 * 0 L66P -- excision $227.90 * 10 L67P -- diverticulum -- repair $461.20 42 L68P -- prolapse -- repair $254.00 42 L69P Correction of atresia of vulva $258.00 42 L70P Vulvectomy $888.00 42 M71P -- with bilateral inguinal node excision $1,667.10 42 M72P -- with bilateral inguinal and pelvic $2,134.70 42 Mnode excision73P Surgical denervation of vulva for pruritus $313.50 42 LvulvaeVagina80P Dilatation of vagina under general $117.70 * 0 Lanaesthesia or IV sedation (includespost op recovery)81P Colpotomy $301.70 * 42 LFistula82P -- recto-vaginal -- repair $654.00 42 M83P -- urethro-vaginal -- repair $762.90 42 M84P -- vesico-vaginal -- repair $2,038.00 42 MSMA FEE GUIDE - P5 - April 1, 2012

SECTION P:OBSTETRICS/GYNAECOLOGYFeeAnaeVaginal cysts85P -- inclusion -- removal $157.00 * 10 L86P -- congenital -- removal $387.30 42 L87P Vaginal atresia -- plastic reconstruction $910.60 42 L88P Vaginectomy $1,302.00 42 M89P Vaginal septum -- excision of $301.70 10 LGenital ProlapseColporrhaphy90P anterior or posterior $524.00 * 42 L91P -- repeat $572.00 42 L105P Paravaginal repair (alternative to anterior $643.10 42 Lrepair)92P -- anterior and posterior . $688.00 * 42 L93P -- repeat $752.00 42 LComplete repair96P Vaginal vault prolapse -- repair $762.90 42 L97P Enterocele repair $604.00 42 L98P Le Fort operation $762.90 42 L99P Manchester operation $608.80 42 L100P Third degree laceration (old) repair $910.60 42 L101P Urethra -- suspension procedure $995.10 42 L103P -- repeat after 42 days $1,046.50 42 L102P Urethra -- pubo vaginal sling $1,071.10 42 L104P Abdominoscacrocolpopexy $1,050.00 42 MCervix and Uterus108P Artificial insemination, per insemination $79.20 * 0109P Cryoconization or loop diathermy of cervix $178.70 0 LCervix110P -- biopsy with or without $64.20 * D Lelectro-cauterization111P -- electro-cauterization $25.80 * 0 L112P -- polyp -- removal -- with or without $64.20 * 0 Lelectro-cauterization113P -- conization with D and C, with or $461.20 10 Lwithout deep cautery, with orwithout polyp removal114P -- biopsy -- excision $70.60 * 10 L115P -- repair or amputation $387.30 42 LRemoval of cervical stump116P -- abdominal $608.80 42 M117P -- vaginal $654.00 42 L118P Dilatation and curettage $196.90 * 0 L120P Hysterotomy $718.00 42 MHysterectomynot billed in addition to adnexal surgery122P -- subtotal $1,020.00 42 M-- Total123P -- abdominal $1,020.00 42 M124P -- vaginal $1,020.00 42 M125P -- Wertheim $2,129.30 42 HSMA FEE GUIDE - P6 - April 1, 2012

SECTION P:OBSTETRICS/GYNAECOLOGYFeeAnaeHysterectomy -- laparoscopic or laparoscopic assisted (not paid inaddition to adnexal surgery)126P Hysterectomy -- subtotal or total -- includes 34P and 134P $1,300.00 42 M130P Conservative surgery for endometriosis $910.60 42 Mincludes presacral neurectomy131P Myomectomy by laparotomy, $728.00 42 Mlaporoscopy or hysterectomy-- singleor multiple -- not billed in addition toadnexal surgery -if done by hysterescopythen hysterescopy and other intrauterineprocedure are included132P Uteroplasty $1,070.00 42 M133P Uterus -- suspension $542.00 42 M134P Salpingectomy and/or oophorectomy and/or $780.00 * 42 Movarian cystectomy -- unilateral orbilateral -- (when second ovary requirescystectomy, the surgery and the contra lateralside may be paid at 75% by report)135P Tubal resection and/or ligation for $478.00 * 42 Msterilization -- unilateral or bilateral -- (payableat 75%, by report when performed as a secondand unrelated procedure at the time of othergynaecological surgery in which fertilitywould otherwise be preserved)Salpingostomy -- not billed in addition toother adnexal surgery236P -- unilateral $782.00 42 M237P -- bilateral $914.00 42 M238P Salpingo-utero-ovario-lysis -- not billed in $782.00 42 Maddition to other adnexal surgery -- unilateralor bilateral137P Tubo-uterine implantation -- not billed in $974.00 42 Maddition to other adnexal surgery138P Broad ligament cyst -- enucleation -- not billed $762.90 42 Min addition to other adnexal surgery139P Ovarian suspension or neurectomy -- not billed $762.90 * 42 Min addition to other adnexal surgery140P Tubal ligation through laparoscope $478.00 * 42 M-- unilateral or bilateral141P Hysteroscopic sterilization by tubal $478.00 42 Mocclusion (Essure)142P Omentectomy - when done in addition to $233.30 * 42 M123P or 134P in cases of malignancy,add143P Reconstruction of fallopian tubes following $970.00 42 Mpathological occlusion -- unilateral (secondtube is payable at 75%)144P Reanastamosis of fallopian tubes $945.00 42 MLaser Vaporization150P -- cervix -- full circumference $461.20 10 L151P -- intraepithelial neoplasia of vulva, $516.80 0 Lvagina or cervical segment251P -- extensive -- vulva and/or vagina $725.50 10 Land/or cervixFor laser therapy of venereal warts (time 30 minutesor less) use 422R. Claim 150P and 422R forcircumferential laser ablation of cervix for CINSMA FEE GUIDE - P7 - April 1, 2012

SECTION P:OBSTETRICS/GYNAECOLOGYplus removal of genital warts -- claims for 251Pfor CIN and/or venereal warts (over 30 minutes) arepayable at $6.00 per minute.FeeBMI Supplement580P Obstetrics and Gynaecology supplement for $112.00 *patients with a Body Mass Index, (Weight[kg]/Height[m] 2 ) greater than 40 or 45 if pregnantand in the third trimester581P Obstetrics and Gynaecology supplement for $169.00 *patients with a Body Mass Index, (Weight[kg]/Height[m] 2 ) greater than 50Obstetrics and Gynaecology supplement(580P and 581P) may be billed with service codes31P to 40P, 41P, 44P to 46P, 48P to 140P, 141P,143P, 150P, 151P, 211P, 212P, 232P to 241P,248P to 279P, 334P, 335P, 350P, 438P and439P.Maximum of one 580P or 581P supplement perpatient per day.Codes 580P and 581P cannot be billed together.SMA FEE GUIDE - P8 - April 1, 2012

SECTION Q:NEUROLOGYVisitsFee3Q Complete assessment $152.00-- includes: pertinent family history,patient history, history of presentingcomplaint, functional enquiry,examination of all parts and systems,diagnosis -- assessment, completerecord, necessary treatment andadvice to the patient-- includes neurological history (family, pastpatient and presenting with functional inquiry);examination of all parts of the nervous systems;diagnostic assessment, complete writen recordingwith mnagement recommendations andadvice to patient and referring physician if any.5Q Partial assessment or subsequent visit $152.00-- includes: history review, history ofpresenting complaint, functionalenquiry, examination of affectedpart(s) or system(s), diagnosis --assessment, record, necessarytreatment and advice to the patient-- includes brief review of presentingneurological complaint; examination ofthe appropriate part/parts ofo the nervoussystem; diagnostic assessment with briefwritten record and management recommendaationsto patient and referring physician if any.9Q Consultation $302.00-- includes all visits necessary, historyand examination, review of laboratoryand/or other data and writtensubmission of the consultant'sopinion and recommendations to thereferring doctor-- full neurological history and examination ofthe nervous system with review of availableinvestigation data/submission of written opinion,to referring physician and appropriateexplanation to the patient.11Q -- repeat $168.00SMA FEE GUIDE - Q1 - April 1, 2012

SECTION Q:NEUROLOGYFeeHospital Care(Payable on day of admission)25Q -- first 10 days, per day $60.00 *26Q -- 11-20 days, per day $60.00 *27Q -- 21-30 days, per day $40.00 *28Q -- thereafter, per day $40.00 *AnaeNote: for hospital discharge by physician, seecode 725A, in Section AProceduresAdditional payments for diagnostic serviceexcluding ECG's, 0, 10 or 42 day proceduresperformed on patients under one (1) year of ageare automatically calculated and paid asexplained in Section A, Paediatric Age Supplement.101Q Manual muscle testing - complete $40.00 D102Q Manual muscle testing - regional $15.60 D103Q Major myoneural study - complete - 11 or $150.00 Dmore units104Q Minor myonerual study - 6 to 10 units $100.00 D105Q Limited study 1 to 5 units $70.00 DNote: a unit is either a segment of a nerveconduction study or an individual muscle106Q Interpretation of nerve conduction $30.00 Dstudy - not payable with a visit service107Q Repetitive nerve stimulation of 2 or $76.00 Dmore muscles108Q Blink reflex bilateral stimulation of facial $40.00 Dnerve with ipsilateral and contralateralrecording or blink reflex109Q Technical fee for physician performance $60.00 * Dof the Nerve Conduction Studies and/orEMG only110Q Complex study - add to appropriate procedure $40.00 * Dor technical code - requires examination(e.g. ICU neuromuscular assessment)120Q Ischemic or Non-ischemic forearm test - $300.00 Dprofessional componentOrgan Donor Assessment140Q Certification of brain death and organ donor $280.00assessment for specialists with appropriatetraining, following health authorityprotocolsSMA FEE GUIDE - Q2 - April 1, 2012

SECTION Q:NEUROLOGYFee150Q Certification of brain death and organ donor $143.00assessment by specialist with appropriatetraining who was providing ICU care to thepatient following health authority protocolsSMA FEE GUIDE - Q3 - April 1, 2012

SECTION R:UROLOGICAL SURGERYVisitsFee5R Initial Assessment $106.00-- of a specific condition includes:pertinent family history, patienthistory, history of presentingcomplaint, functional enquiry,examination of affected part(s) orsystem(s), diagnosis, assessment,necessary treatment, advice to the patientand record of service provided7R Follow-up Assessment $67.20-- includes: history review, functionalenquiry, examination, reassessment,necessary treatment, advice to the patientand record of service provided9R Consultation $159.00-- includes all visits necessary, historyand examination, review of laboratoryand/or other data and writtensubmission of the consultant'sopinion and recommendations tothe referring doctor11R -- repeat $80.8013R Written advice to referring physician on $81.00the management of a case based uponreview of IVP and/or other x-rays byUrological Surgeon(payable once per case only)Hospital Care(Payable on day of admission)25R -- first 10 days, per day $56.80 *26R -- 11-20 days, per day $53.40 *27R -- 21-30 days, per day $24.40 *28R -- thereafter, per day $24.40 *Note: for hospital discharge by a physician,see code 725A, in Section A.SMA FEE GUIDE - R1 - April 1, 2012

SECTION R:UROLOGICAL SURGERYProcedures Fee AnaeAdditional payments for diagnostic serviceexcluding ECG's, 0, 10 or 42 day operativeprocedures performed on patients under one (1) yearof age are automatically calculated and paid asexplained in Section A, Paediatric Age Supplement.29R Diagnostic bladder catheterization -- in $15.80 * D Loffice procedure30R Cystoscopy $208.00 D L31R -- with ureteral catheterization or $258.00 D Lretrograde pyelography33R -- Split function renal study with $276.00 D Linterpretation38R -- Voiding cystourethrogram in operating $65.20 * D Lroom, addSeminal fluid analysis35R -- count, motility and morphology $38.20 * D36R Prostatic secretion (microscopic examination) ... $9.00 D37R Intra-penile vasoactive injection, each to $26.40 * 0a maximum of 2 units per day39R Assessment of penile and/or testicular blood $28.80 * Dflow and/or varicocele, including measurementof penile blood pressure .Urodynamics InvestigationCystometrogram (Cmg)400R -- technical component $78.40 * D500R -- technical component using $137.00 * Ddisposable catheter401R -- professional component $118.00 * DElectromyography (Emg)402R -- technical component $74.00 * D403R -- professional component $182.00 * DUrethral pressure profile404R -- technical component $78.80 * D405R -- professional component $118.00 * DUroflow406R -- technical component $25.80 * D407R -- professional component $52.80 * DVenereal warts -- either sexElectrocoagulation or chemocoagulationof venereal warts (includes treatmentwith Podophyllin)420R -- initial $214.00 * 0421R -- repeat within 10 days $66.40 * 0422R Venereal warts -- operation -- in hospital $210.00 * 10 LSMA FEE GUIDE - R2 - April 1, 2012

SECTION R:UROLOGICAL SURGERYFeeAnaeEndoscopic40R Fulguration or biopsy of bladder $332.00 42 L-- tumors and/or other lesionsTransurethral41R -- lithopexy $848.00 42 L42R -- removal of ureteral stone by $528.00 42 Lmanipulation43R Periurethral injection of teflon for $528.00 10 Lincontinence (includes cystoscopy)44R -- bladder tumor resection $990.00 42 M46R -- secd'y haemorrhage -- endoscopic $332.00 42 Ltreatment -- exempt from repeatsurgical rule47R -- bladder neck resection $786.00 42 L48R -- resection of ureterocele $332.00 42 L49R -- resection of posterior urethral valve $710.00 42 L50R Ureteroscopy - with or without biopsy $982.00 D L(includes cystoscopy)51R -- with removal of stone $1,314.00 4252R -- with ultrasonic disintegration $167.00 42add to 51R53R Uteroplasty-- endoscopic with balloon $624.00 0 Ldilitation of uteric stricture with or withoutstent not billable with 51RPenis59R Incisional biopsy of glans penis $142.00 * 10 L60R -- amputation $1,570.00 42 M61R -- with excision (radical) of nodes $2,362.00 42 M62R -- partial $1,314.00 42 MPenile implant63R -- semi-rigid $1,037.0064R -- hydraulic $1,556.00Circumcision (routine circumcision is not insured)65R -- without anaesthesia $230.00 * 066R -- under anaesthesia -- child $510.00 * 42 L67R -- adult $510.00 * 42 L68R Dorsal slit or preputial adhesiolysis $258.00 * 0 Lunder EMLAUrethra69R -- meatotomy -- with plastic repair $182.00 10 L70R -- dilation $131.00 * 0 L73R -- surgical repair anterior urethral $1,314.00 42 Lrupture74R -- repair posterior -- primary repair $1,788.00 42 Mincluding suprapubic cystotomySMA FEE GUIDE - R3 - April 1, 2012

SECTION R:UROLOGICAL SURGERYFeeAnae79R Repeat repair of anterior or posterior $1,754.00 42 Lurethral rupture or stricture (related to73R or 74R)80R Urethral stent for prostatic hypertrophy or $576.00 42 Lstricture - includes cystoscopy75R Urethrotomy $396.00 42 L76R Removal of foreign body from urethra $354.00 10 L77R Urethral diverticulectomy $1,048.00 42 L78R Urethrocutaneous fistula -- repair $1,174.00 42 LBladder89R Chemotherapeutic bladder irrigation for $131.00 0 Ltreatment of malignancy or of interstitialcystitis189R Bladder hydrodistension for patients with $131.00 0 Lintersticial cystitis or clinical presentationstrongly suggestive of interstitial cystitis(payable in addition to cystoscopy)Cystotomy90R -- with trochar $330.00 * 10 L91R -- with removal of stone, foreign body, $848.00 42 Letc.92R -- excision, electro-resection or $602.00 42 Lfulguration of bladder tumor with orwithout radiation implantsCystectomy93R -- partial $1,314.00 42 M94R -- partial with ureteral reimplantation $1,850.00 42 M95R -- total cystectomy with $4,402.00 42 Hureterointestinal transplant96R -- with ureteroileal conduit $6,560.00 42 H97R -- with rectal bladder and colostomy $5,504.00 42 H100R Diverticulectomy $1,578.00 42 M101R Resection ureteral stump $942.00 42 L102R Ileocystoplasty $3,936.00 42 H103R Surgical repair of ruptured bladder $1,314.00 42 MUreterocutaneous anastomosis104R -- unilateral $768.00 42 M105R -- bilateral $1,104.00 42 M106R Ileal conduit $3,276.00 42 HUreterosigmoid anastomosis107R -- unilateral $1,104.00 42 M108R -- bilateral $1,434.00 42 M109R Bladder neck plasty $1,238.00 42 M110R Insertion of artificial urinary sphincter $1,812.00 42 MSMA FEE GUIDE - R4 - April 1, 2012

SECTION R:UROLOGICAL SURGERYFeeAnaeProstate120R Prostate -- abscess -- incision $276.00 * 42 L121R Prostate -- biopsy -- needle $170.00 D L122R Open perineal prostatic biopsy $1,104.00 42 L126R Ultrasound guided prostate biopsy $266.00 D L123R Prostatectomy -- or laser ablation $1,314.00 42 M124R Radical prostatectomy (excludes exploration $3,936.00 42 Hand biopsy of pelvic lymph nodes)125R Seminal vesiculectomy $1,816.00 42 MKidney and Ureter130R Kidney -- rupture -- repair $2,238.00 42 H131R Renal biopsy -- percutaneous -- unilateral $250.00 D L133R Renal biopsy -- open exposure $822.00 42 M134R Perinephric abscess -- drainage $910.00 42 M135R Exploration of kidney (not paid in addition $1,238.00 42 Mto Renal surgery)Nephrectomy136R -- complete or partial $2,622.00 42 H138R -- thoraco-abdominal radical $3,144.00 42 Hnephrectomy139R Nephrolithotomy or nephrotomy, $1,804.00 42 Mpyelolithotomy or pyelotomy140R Nephropexy -- (not paid in addition to $548.00 42 MRenal surgery)141R Nephrostomy or pyelostomy and $1,314.00 42 Mureterostomy142R Ileal substitution for ureter $2,748.00 42 H143R Exploration ureter for lesion or trauma in $936.00 42 Mconjunction with or for other surgeons144R Plastic -- renal pelvis and/or ureter $2,360.00 42 M145R Ureterolysis or pelviolysis $1,318.00 42 MUreterolithotomy146R -- upper 2/3 $1,290.00 42 M147R -- lower 1/3 $1,214.00 42 M158R -- following previous ureteral surgery . $1,260.00 42 M148R Resection of ureterovesical junction $942.00 42 M149R Horseshoe symphysiotomy $1,210.00 42 M150R Hypothermia to kidney, add $89.00 * 42Ureteroneocystostomy151R -- single $1,710.00 42 M152R -- bilateral $2,130.00 42 M153R Repair of ureteral fistula $1,608.00 42 M154R Intubated ureterotomy and/or ureterolysis $1,290.00 42 MSMA FEE GUIDE - R5 - April 1, 2012

SECTION R:UROLOGICAL SURGERYFeeAnae155R Renal cyst -- excision of -- single or multiple $1,314.00 42 M-- one kidneyNephrostomy tube156R -- routine change $50.80 * 0 L157R -- emergency reinsertion $110.00 0 LUreteral stent258R -- placement -- unilateral $342.00 10 L259R -- replacement $342.00 10 L659R -- removal $254.00 0 LScrotum and Contents160R Open testicular biopsy $258.00 0 L161R Epididymectomy -- unilateral $802.00 42 LHydrocele or epididymal cyst162R -- aspirate $66.40 * 0 L163R -- surgical repair $552.00 * 42 LVaricocele164R -- repair $652.00 * 42 L165R -- with exploration of inguinal canal $652.00 * 42 LOrchidectomy166R -- unilateral $336.00 * 42 L167R -- bilateral $652.00 * 42 L168R Retroperitoneal exploration for testicle $964.00 42 M169R Orchidopexy -- unilateral. Includes $1,174.00 42 Lsimple herniotomy. Herniorrhaphypaid in addition170R Orchidolysis $88.80 * 42 L171R Torsion -- testis or appendix testis with $1,070.00 * 42 Lfixation of contralateral testis180R Orchidectomy with excision at internal $652.00 42 Lring -- unilateral190R Vasectomy -- unilateral or bilateral $530.00 * 42 L191R Re-anastamosis of vas deferens with $1,556.00intraluminal splinting plus Anae. fee of $810.00192R Epididymo-vasostomy -- unilateral $1,080.00 42 L193R Insertion of testicular prosthesis, $1,070.00 * 42 Lindependent procedure194R Vasogram - unilateral or bilateral $117.00 * D L-- in conjuction with open scrotalprocedure, add195R -- independent procedure unilateral $110.00 * D Lor bilateralSMA FEE GUIDE - R6 - April 1, 2012

SECTION R:UROLOGICAL SURGERYFeeAnaeIntra-abdominal202R Exploration and biopsy of pelvic lymph nodes $1,314.00 42 M203R Pelvic lymphadenectomy $1,966.00 42 MPercutaneous Nephrolithotripsy251R Dilatation of nephrostomy tract, add $258.00 0252R Nephroscopy through nephrostomy tract, add $332.00 D253R Removal of calculi by basket, ultrasonic $786.00 42 Mdisintegration or electrohydrauliclithotripsy -- small -- single254R -- multiple $1,314.00 42 M255R -- large -- (greater than 2 cm) $1,838.00 42 M256R Extracorporal Shockwave Lithotripsy (ESWL) $1,006.00 42 M--unilateralRenal HomotransplantationAll services are billed in the name of therecipient by the surgeons and internists andinclude all services to a living donor andthe recipient on day of transplant and for42 days thereafter except:(a) a consultation by a physician other thanthe Urological or Vascular surgeons, orInternists;(b) anaesthetic services.Donor nephrectomy -- living donor or cadaver300R One surgeon $3,050.00 42 M301R Two surgeons -- first $1,314.00 42 M311R -- second $1,194.00 42 M302R Renal perfusion by other than a member $318.00 0of the transplant teamRenal implantation303R -- Urological surgeon $1,070.00 42 M304R -- Vascular surgeon $2,244.00 42 H340R Intra-operative biopsy of donor $103.00 Dkidney -- add305R -- Internist services -- total $6,468.00 42(includes 306R and 307R)306R Internist services in donor kidney $408.00 0procurement in other than the transplantcenter307R Internist services in the provision of $6,540.00 42renal implant and follow-up servicesSMA FEE GUIDE - R7 - April 1, 2012

SECTION R:UROLOGICAL SURGERYFee308R Follow-up of renal implant patient $510.00308R is payable for a visit to provideassessment and ongoing managementof a patient's condition following a kidneytransplant. This service is payable tothe physician designated as the mostresponsible physician for monitoring thepost-transplant status of the patient.-- not payable in addition to other visit servicesor dialysis, or within 42 days of the previous308R.-- limited to six 308R services per patient peryear (beginning April 1 of each year).-- not payable in the first 12 months followinga transplant.580R Urology surgery supplement for patients with a $113.00Body Mass Index, (Weight[kg]Height[m]2) greaterthan 40-Maximum of one 580R supplement per patient per day-Supplement 580R may be billed by urologists withall R Section procedures done in the operating room-Service codes 30R and 31R are exempt from thissupplementSMA FEE GUIDE - R8 - April 1, 2012

SECTION S:OPHTHALMOLOGYVisitsFee5S Initial Assessment $130.00-- of a specific condition includes:pertinent family history, patienthistory, history of presentingcomplaint, functional enquiry,examination of affected part(s) orsystem(s), diagnosis, assessment,necessary treatment, advice to the patientand record of service provided7S Follow-up assessment $79.00-- includes: history review, functionalenquiry, examination reassessment,necessary treatment, advice to the patientand record of service provided8S Neuro-Ophthalmology follow assessment $92.20-- includes history review, functionalenquiry, examination reassessment,necessary treatment, adviceto the patient and record of service provided (only payable toto physicians with approved training inneuro-ophthalmology)9S Consultation $164.00-- includes all visits necessary, historyand examination, review of laboratoryand/or other data and writtensubmission of the consultant'sopinion and recommendations tothe referring doctor10S Neuro-ophthalmology consultation $246.00-- includes all visits necessary, historyand examination, review of laboratoryand/or other data and writtensubmission of the consultant's opinionand recommendations to the referringdoctor (only payable to physicianswith approved training inneuro-ophthalmology11S -- repeat $88.0012S Low vision assessment (limited to one benefit $262.00per beneficiary per 12-month period)6S Routine examination of eyes $136.00-- means an examination of the eyes that shallinclude: case history; visual acuity; externalexamination; assessment of extraocularSASKATCHEWAN MEDICAL ASSOCIATIONGUIDE TO FEES - S1 - April 1, 2012

SECTION S:OPHTHALMOLOGYmuscles; convergence testing; pupil response;accommodation; examination of cornea, lens,media, fundus; determination of refractive erroror change; instruction, information and adviceto the patient with respect to the status of his/heror their vision and its future management;provision of the necessary prescription.FeeAnaeHospital Care(Not payable with a visit or consultationservice on day of admission)25S -- first 10 days, per day $50.00 *26S -- 11-20 days, per day $50.00 *27S -- 21-30 days, per day $22.00 *28S -- thereafter, per day $22.00 *Note: for hospital discharge by physicians,see code 725A in Section A.ProceduresAdditional payments for diagnostic serviceexcluding ECG's, 0, 10 or 42 day operativeprocedures performed on patients under one (1) yearof age are automatically calculated and paid asexplained in Section A, Paediatric Age Supplement.32S Tension -- measured with a tonometer -- $22.00 * Dbilateral332S Diurnal tension curve -- bilateral $144.00 D33S Gonioscopy -- bilateral $16.00 * D534S Formal orthoptic assessment interpretation $40.00 D580S Corneal pachymetry (repeat by report $12.00 * Donly) - bilateral15S Cycloplegic Retinoscopy-under 11 years age $40.00 D535S Orthopic Technical Fee-bilateral-limit of one per year - $40.00 Dadd to 5S 6S,7S,9S,10S,11S,12S 534S651S Automated perimetry/specular microscopy/topography $10.00 Dtechnical fee-bilateral-add to 34S,35S,36S,650S,671S -1 per patient visit579S Screening visual fields (FDT or similar) technical fee $4.00 D- bilateral-limit of 1 per visit-only payable with 34SOptical Coherence Tomography (OCT)Not to be used for routine screening of patientsand limit of one per year (professional andtechnical) when billed for monitoring glaucomapatients581S Optical coherence tomography $50.00 D(OCT) - bilateralSASKATCHEWAN MEDICAL ASSOCIATIONGUIDE TO FEES - S2 - April 1, 2012

SECTION S:OPHTHALMOLOGYFee582S Optical coherence tomography $50.00 * D(OCT) - technical feeAnaeVisual Field34S Screening visual field including tangent $31.00 * Dscreen, auto plot-arc perimetry andfrequency doubling screening -- bilateral35S -- central threshold visual field -- bilateral $38.00 * D36S -- peripheral and central visual field -- bilateral $78.00 * D422S Manual static and kinetic perimetry -- bilateral $78.00 * D37S Provocative tests for glaucoma -- bilateral $24.00 * DFundus examination under general anaesthetic39S -- unilateral or bilateral $344.00 * D LForced Duction Test424S -- local $52.60 * D425S -- general $93.60 * D LFundus or Slit Lamp Photography652S Professional component -- bilateral $13.90 * D653S Technical component -- bilateral $13.90 * DFluorescein Angiography40S -- technical $57.80 * D(Apparatus owned by physician and injectionby physician. Use 111A if I.V. injectiononly by the physician)41S -- professional $57.80 * D42S Visually evoked occipital response $24.00 * Dinterpretation43S Electroretinography interpretation $44.00 * D44S Electro-oculography interpretation $44.00 * DColor vision assessment (F.M. 100 Hue Testor Pickford Anomaloscope)45S -- technical component $17.10 * D46S -- professional component $32.00 * D650S Contact or non-contact specular microscopy $44.00 * Dof corneal endothelium -- professionalcomponent -- unilateral429S Laser Inferometry $10.80 * D430S Potential Acuity Meter $4.20 * D656S Exophthalmometry $12.80 * D658S Dark adaptation curve -- both eyes $39.60 * D-- professional component661S Hess or Lees test $40.00 * D664S Indirect ophthalmoscopy with scleral $36.40 * Ddepression for complete examination offundus and diagraming -- unilateralor bilateralSASKATCHEWAN MEDICAL ASSOCIATIONGUIDE TO FEES - S3 - April 1, 2012

SECTION S:OPHTHALMOLOGYFee680S Infrared pupillography -- bilateral $41.60 D681S Eye movement videography/ $41.60 Dphotography -- bilateral682S Quantification of relative afferent $41.60 Dpupillary defect with neural densityfilters -- bilateral683S Diagnostic pupillary drop $52.00 Dtesting -- bilateralCodes 680S to 683S are only billable by physicianswith approved neuro-ophthalmology training.AnaeEyelids60S Abscess -- incision $44.60 * 0 L62S Blepharoplasty -- Excision of skin $246.10 10 Land/or muscleInsured if interference with visual axis by preauthorization(see Cosmetic Surgery Protocol - Section N).If accompanied by orbital septal herniationuse 276N. Blepharoplasty of lower lid 277Nbilled only when orbital fat/orbital septalpathology due to endocrine or other diseaseor ophthalmological confirmation of interferencewith bifocal lens.Ptosis repair includes associated blepharoplasty.63S Chalazion -- removal $120.00 * 10 L64S -- under general anaesthetic or IV sedation $240.00 * 10 L(includes post-op recovery)65S Cauterization -- lid $40.00 * 0 LTrichiasis66S Epilation -- unilateral $44.00 * 0 L431S Electrolysis -- unilateral $62.10 * 10 L432S Cryotherapy -- unilateral $119.00 10 LDistrichiasis436S Permanent repair -- per lid $492.20 42 L67S Ziegler puncture $58.90 * 10 LTarsorrhaphy68S -- temporary or reversal $130.00 10 L69S -- permanent -- double adhesion $320.00 42 LEctropion80S -- surgical repair $640.00 42 LEntropion81S -- surgical repair $640.00 42 LPtosis75S -- simple repair $800.00 42 L439S -- complicated repair with graded $196.90 42 Ltarsomeuller resection, add440S -- with fascia lata sling, add $196.90 42 LSASKATCHEWAN MEDICAL ASSOCIATIONGUIDE TO FEES - S4 - April 1, 2012

SECTION S:OPHTHALMOLOGYFeeAnae441S -- with levator excision, add $196.90 42 L442S -- with aponeurosis reinsertion, add $196.90 42 LBlepharoplasty included in the billfor ptosis repair.Lid Lengthening444S Graded Meullerectomy $738.30 42 L445S -- with levator recession, add $124.10 42 L446S -- with scleral graft, add $124.10 42 LEyelid or Conjunctival Tumor70S Excision -- without sutures $100.00 * 10 LExcision -- repair with sutures (Use 380N)77S Full thickness excision of benign or $360.00 42 Lmalignant tumor with plastic repairusing conjunctivaLid Laceration72S -- simple repair $120.00 * 10 L448S -- full thickness $308.20 42 L449S full thickness -- lid margin $369.20 42 L454S full thickness plus levator division $476.00 42 L73S -- repair of canaliculus -- old or recent $800.00 42 LLid Defect450S closure with rotation flap $492.20 42 L451S closure with rotation flap plus $124.10 42 Lcantholysis, add452S closure with temporal flap and $320.00 42 Lcantholysis, add453S closure with free posterior lamellar $308.20 42 Lgraft, addUpper or lower eyelid bridge flap455S -- first stage $984.40 42 L456S -- second stage $184.00 42 L457S Free composite eyelid graft $984.40 42 L458S Medial Canthoplasty $615.30 42 LMedial Canthal tendon injury459S -- repair $476.00 42 L460S -- with boney fixation, add $180.00 42 L461S Medial or lateral cantholysis $242.00 42 L462S Lateral canthopexy -- primary $476.00 42 LLacrimal TractDuct Probing50S -- local anaesthesia $40.00 * 051S -- general anaesthesia $240.00 * 0 LSASKATCHEWAN MEDICAL ASSOCIATIONGUIDE TO FEES - S5 - April 1, 2012

SECTION S:OPHTHALMOLOGYFeeAnae52S Duct probing and insertion of plastic tube $328.00 10 Lor similar method -- total care464S -- with turbinate fracture, add $50.00 * 0 L466S Tube change or reinsertion -- local $124.10 0 Lor general after 10 days54S Dacryocystectomy $453.70 42 L55S Dacryocystorhinostomy $1,050.00 42 M468S -- with lacrimal bypass or canalicular $147.70 42 Lreconstruction, add469S "Three Snip" procedure on punctum $147.70 10 L470S Canaliculotomy $73.80 * 0 L471S Closure of punctum by cautery -- unilateral $147.70 0 Lor bilateral472S Drainage of lacrimal sac abscess $123.00 * 0 L573S Punctual Plugs - per punctum - maximum of 2 $130.00 10Extraocular MusclesRecession, resection, myotomy, myectomy,oblique weakening or strengthening130S -- first muscle $892.00 42 M131S -- second muscle -- either eye -- add $666.00 42 M132S -- any additional muscle(s) -- either $230.00 42 Meye -- add133S -- adjustable suture technique per muscle $500.00 42 Madjusted -- add134S -- two muscle transposition procedure $1,602.00 42 MConjunctiva -- Cornea -- Sclera88S Removal of corneal tattooing $136.00 10 L89S Biopsy of conjunctiva $84.00 * D LForeign body or bodies -- removal90S -- unembedded $40.20 * 0 L--embedded91S -- local anaesthesia $67.00 0 L106S -- general anaesthesia $222.00 10 L671S Corneal topography - interpretation fee (only $52.00 Dfor corneal pathology, i.e. not billable forrefractive surgical assessments) - unilateralor bilateralL92S Keratectomy -- superficial $720.00 42 LKeratoplasty93S -- lamellar $1,100.00 42 L94S -- penetrating $1,990.00 42 M95S Pterygium -- any method $600.00 42 L96S Subconjunctival injection $30.00 * 0 L97S Corneal ulcer -- cauterization -- initial $36.40 * 0 Lor repeatSASKATCHEWAN MEDICAL ASSOCIATIONGUIDE TO FEES - S6 - April 1, 2012

SECTION S:OPHTHALMOLOGYFeeAnae98S Relaxing corneal incisions following $500.00 42 Lcorneal transplantation(Does not apply to radial keratotomy)Phototherapeutic keratectomy for anteriorscarring, hereditary congenital dystrophy orrecurrent erosion syndrome- requires prior approval300S -- professional fee $720.00 42 L301S -- technical fee (physician owned equipment) $1,920.00 * 42 L250S Removal of corneal sutures, by different surgeon $130.00 * 0or same surgeon beyond post-op period (doesnot apply to cataract or trabeculectomy cornealsuture removal)Conjunctival flap over ulcer or wound99S -- simple . $440.00 42 L107S -- Gunderson or complicated $1,000.00 42 MWounds -- suture100S -- conjunctiva $240.00 * 10 L101S -- corneal or sclera -- without $1,100.00 42 Mcomplication102S -- with prolapse by conjunctivaplasty $1,350.00 42 M103S Retrobulbar injection of alcohol $120.00 * 0 L104S Excision of corneal dermoid $600.00 42 L474S EDTA removal of band keratopathy $490.00 10 L475S Conjunctival resection for corneal melt $308.20 0 L476S Cyanoacrylate for corneal melt $450.00 0 L522S Re-operation through conjunctivia-for glaucoma, stabismus $200.00 42 Mand sclera buckling surgery-unilateral-can add to160S, 130S, 131S, 132S, 133S, 169S477S Epikeratophakia $1,353.60 42 LPre-authorization required. Insured if:1. Adult aphakia with low endothelial count and intoleranceto contact or intraocular lens.2. Pediatric aphakia with failure of visual rehabilitation3. Keratoconus --with contact lens intoleranceNot an insured service when done as cosmetic procedure.IrisIridotomy182S -- laser per eye $210.00 10478S -- surgical $443.00 42 L163S Iridectomy -- surgical $443.00 42 L105S Iridodialysis repair $500.00 42164S Irrigation -- anterior chamber, $440.00 42 Lthrough corneal incisionSASKATCHEWAN MEDICAL ASSOCIATIONGUIDE TO FEES - S7 - April 1, 2012

SECTION S:OPHTHALMOLOGYFeeAnaeSynechotomy165S -- anterior chamber, surgical $246.10 42 L187S -- anterior chamber, laser $160.00 LParacentesis166S -- aqueous $64.00 0 L167S -- vitreous $100.00 0 L186S Photomydriasis $270.70 10 LGlaucoma180S Laser trabeculoplasty -- per eye $308.00 10159S Cyclodiathermy, cycloelectrolysis or $467.60 42cyclocryothermyFiltering operation160S -- standard $1,200.00 42 M520S -- with any seton device in the anterior $520.00 42chamber or through pars plana, add ......521S -- with the use of anti-metabolite drugs $180.00 42 M-- add190S Cyclodialysis $184.00 10 LGoniotomy and/or goniopuncture161S -- unilateral $393.80 42 L162S -- repeat $246.10 42 L480S Post op trabeculectomy - cutting of $124.10 0 LsuturesLensCataract135S -- complete treatment -- all forms, $935.20 42 Lchild or adult136S -- Implantation of prosthetic intraocular $196.90 * 42 Llens, addProsthetic Intraocular lens236S -- repositioning $284.00 0 L336S -- removal $268.60 10 L479S Removal and replacement $780.00 42 L539S Repositioning with suture of haptic to $800.00 42 LscleralSecondary implantation of lens prosthesis142S -- simple -- intact vitreous $700.00 42 LComplicated with vitrectomy, usevitrectomy codesCrystalline Lens - Removal of Dislocated139S -- anterior chamber $738.30 42 L137S Capsulectomy $500.00 42 LSASKATCHEWAN MEDICAL ASSOCIATIONGUIDE TO FEES - S8 - April 1, 2012

SECTION S:OPHTHALMOLOGYFeeAnae138S Capsulotomy or discission of secondary $300.00 42 Lmembranes (surgical)189S Posterior capsulotomy (laser) $178.70 10 LComplex Cataracts673S Pupil expansion device, insertion and removal-unilateral- $172.00 42 Lcan be added to 135S, 139S, 142S, 226S, 236S674S Capsular tension ring or segment insertion-unilateral- $172.00 42 Lcan be added to 135S, 139S, 142S, 226S, 236S675S Capsular staining by any method-unilateral-can be $50.00 42 Ladded to 135S, 139S, 142S, 226S, 236SSclera481S Scleral Patch Graft $861.40 42 M482S Noniatrogenic scleral dehiscence or $369.20 42 Mrupture -- repair483S Tumor of ciliary body By Report 42 M171S Posterior sclerotomy with or without $300.00 10 Linsufflation of anterior chamberOrbit108S Harvesting of donor eyes -- one or both $600.00 0 L-- for corneal transplant109S Exenteration $1,400.00 42 M110S Abscess -- incision and drainage $552.00 42 L111S Enucleation $900.00 42 M112S -- with insertion of an integrated $240.00 42 Morbital ocular implant in scleralshell, add113S Extruded implant - replace - secondary $570.00 42 Loperation540S Secondary drilling of integrated $374.00 42 Lorbital implantDermal Fat Graft313S Immediate following enucleation $430.10 42 L485S -- delayed replacement of extruded $984.40 42 Limplant by graft78S Fornix Restoration -- minor $700.00 42 L487S -- with mucous membrane graft, add $246.10 42 L488S -- with autogenous conjunctival $246.10 42 Ltransplant, add413S Reversal of anophthalmic socket with $670.00 42 Lsecondary integrated implantTumor114S Excise anterior tumor -- simple removal $980.00 42 M489S Excise posterior tumor $1,524.00 42 M490S Biopsy anterior tumor $654.00 10 LSASKATCHEWAN MEDICAL ASSOCIATIONGUIDE TO FEES - S9 - April 1, 2012

SECTION S:OPHTHALMOLOGYFeeAnae491S Biopsy posterior tumor $900.00 10 L292S Exploration of orbital floor or medial wall $440.00 42 Mfor suspected blowout fracture293S Repair of orbital blowout fracture (floor $708.00 42 Mor medial wall) -- first wall294S Repair of orbital blowout fracture (floor or $530.00 42 Mmedial wall) -- second wall, add -- by report119S Lateral orbitotomy (Kronlein's procedure) $1,900.00 42 Mor other decompression by reportRetina170S Retinal tear, complete treatment by $492.20 42 Ldiathermy, cryosurgery or laser174S Retinal tumor -- treatment by laser $800.40 42 L670S Retinal photography - interpretation fee $52.00 * D-- bilateralDiabetic retinopathy or similar vascularabnormality, treatment by laser -- per eye175S -- initial treatment session $590.60 42 L176S -- subsequent treatment per session $290.00 0 L177S Retinal degeneration or detachment -- treatment $492.20 42 Lby diathermy, cryosurgery, or laser with orwithout hole178S Peripheral retinal diathermy, cryosurgery $492.20 42 Lor photocoagulation169S Scleral buckling for retinal detachment $1,550.00 42 Mincludes -- diathermy, cryo or laser(includes 232S)251S Removal of scleral buckle hardware by $209.70 10 Ldifferent surgeon or same surgeonbeyond post-op periodMacula493S Photocoagulation of choroidal $492.20 42 Lneovascular membrane494S -- subsequent treatment $369.20 42 L495S Focal Photocoagulation of significant $492.20 42 Ldiabetic macular edema496S -- subsequent treatment $369.20 42 LGrid and focal therapy not billed together.Maximum benefit billable under codes 493S to496S in any six consecutive month periodper eye. May be exceeded if extenuatingcircumstances (by report) $1,476.60SASKATCHEWAN MEDICAL ASSOCIATIONGUIDE TO FEES - S10 - April 1, 2012

SECTION S:OPHTHALMOLOGYFeeAnae497S Photodynamic therapy (Visudyne) $684.00 42 Lapproved for cases of pathologic myopiaor the classic form or age related maculardegeneration in patients with predominatelysubfoveal choroidal neovascularizationand choroidal neurovascularizationsecondary to histoplasmosis -- unilateralVitreousAnterior vitrectomy -- planned220S -- with or without penetrating wound $577.80 42 M222S -- with corneoscleral laceration $209.70 42 Mrepair, add223S -- with uveal tissue prolapse and $147.70 42 Mrepair, add224S -- with lensectomy, add $196.90 42 L136S -- Implantation of prosthetic intraocular lens, add $196.90 * 42 LPosterior vitrectomy -- planned(includes anterior vitrectomy)230S -- pars plana $1,420.00 42 M757S -- with intravitreal injection of silicone oil, add $180.00 42 L232S -- with endophotocoagulation, add $246.10 * 42 L224S -- with lensectomy, add $196.90 42 L225S -- with preretinal membrane peeling, add $492.20 42 L136S -- Implantation of prosthetic intraocular lens, add $196.90 * 42 L325S -- removal of dislocated crystalline lens or $720.00 42 Lcataract from the vitreol cavity, add226S Posterior vitrectomy with cataract extraction $674.10 42 Mvia separate anterior approach (includeslensectomy), add515S Air/gas/fluid exchange, add $308.20 42 L516S Air/gas/fluid exchange, repeat $184.00 0 L233S Removal of foreign body from anterior chamber $124.10 42 L(magnetic or non magnetic), add234S Removal of foreign body from posterior chamber $246.10 42 M(magnetic or non magnetic), add141S Removal of foreign body from anterior or $603.50 42 Mposterior chamber or vitreous withoutvitrectomy -- any method252S Post-operative vitreous cavity washout $246.10 0 Lby different surgeon or same surgeonbeyond post-op periodIntraocular fluid/gas exchange254S -- independent procedure $369.20 42 L517S -- removal $246.10 42 LSASKATCHEWAN MEDICAL ASSOCIATIONGUIDE TO FEES - S11 - April 1, 2012

SECTION S:OPHTHALMOLOGYFeesAnae755S Vitreous tap with intravitreal injection of $380.00 0 Lantiobiotic/steroids in the management ofbacterial endophthalmitis756S Intravitreal injection of drugs $200.00 0 L518S Pneumatic retinopexy with cryotherapy $990.00 42 MDissection of vitreous bands or membraneswith Yag laser285S -- anterior segment $344.50 42286S -- posterior segment $738.30 42625S Amniotic membrane transplantation-unilateral-second $750.00 42 Meye same day paid at 75%Laser Technical Fees181S -per eye (unilateral)-may be added to 170S, 174S, 175S, $40.00 D176S, 178S, 180S, 182S, 186S, 187S, 189S, 285S, 286S,493S, 494S, 495S, 496S, 497S- laser owned and maintained by physicianSASKATCHEWAN MEDICAL ASSOCIATIONGUIDE TO FEES - S12 - April 1, 2012

SECTION T:OTOLARYNGOLOGYVisitsFee5T Initial assessment $110.00-- of a specific condition includes:pertinent family history, patienthistory, history of presentingcomplaint, functional enquiry,clinical examination of affectedpart(s) or system(s), diagnosis,tentative or final, necessary treatment,advice to the patient and record of serviceprovided7T Follow-up assessment $90.00-- includes: history review, functionalenquiry, clinical examinationdiagnosis, tentative or final,necessary treatment, advice to the patientand record of service provided9T Consultation $160.00-- includes all visits necessary, historyand examination, review of laboratoryand/or other data and writtensubmission of the consultant'sopinion and recommendationsto the referring doctor11T -- repeat $88.00Hospital Care(Payable on day of admission)25T -- 1-10 days, per day $104.00 *26T -- 11-20 days, per day $104.00 *27T -- 21-30 days, per day $98.00 *28T -- thereafter, per day $98.00 *Note: for hospital discharge by physician,see code 725A, Section A.ProceduresAdditional payments for diagnostic serviceexcluding ECG's, 0, 10 or 42 day operativeprocedures performed on patients under one (1) yearof age are automatically calculated and paidas explained in Section A, Paed. Age Supplement.SMA FEE GUIDE - T1 - April 1, 2012

SECTION T:OTOLARYNGOLOGYFee430T Screening audiogram (not to be billed for $30.60 * DWelch Allyn type audioscope)Diagnostic pure tone audiogram in sound-proofroom including thresholds and four frequencies431T -- air $25.70 * D432T -- air and bone $50.30 * D433T Speech reception threshold $8.60 * D434T Discrimination score $17.10 * D435T One or more of -- most comfortable level, $17.10 * Dspeech detection threshold, stengertest, ABLB or tone decay, total537T Impedance hearing testing $13.90 * D(e.g. Impedance tympanometry and/oracoustic reflexes)Anae438T Reflex decay $13.90 * D439T Conditioned play audiometry $50.30 * D440T V.R.A. requiring two testers $67.40 * D441T T.R.O.C.A. requiring two testers $67.40 * D442T Vestibular caloric test $17.10 * DElectronystagmography including gaze,positional and caloric testing443T -- test and interpretation $165.90 * D444T -- interpretation only $58.90 * D445T Canalolith repositioning maneuver for $20.00 Dbenign paroxysmal positional vertigoEarD51T Catheter inflation . $34.20 * 0Cerumen -- removal includes syringing52T -- simple (bilateral) -- $54.00 * 0not payable with a consultation53T -- impacted -- under injected local or $203.30 * 10 Lgeneral anaesthesia.350T Removal of cerumen under magnification $34.20 * 0(e.g. Hotchkiss otoscope or binocular)(bilateral)Foreign body -- removal54T -- simple $40.00 * 0 L55T -- complicated -- under injected local or $203.30 * 10 Lgeneral anaesthesia56T -- involving post-aural incision $500.00 42 L57T Paracentesis of eardrum $100.00 * 0 LSMA FEE GUIDE - T2 - April 1, 2012

SECTION T:OTOLARYNGOLOGYFeeAnaePolyp58T -- removal -- simple $62.10 * 10 L59T -- removal under local or general $203.30 * 10 Lanaesthesia61T Labyrinthotomy - total $1,243.30 42 L62T Endolymphatic sac surgery -- initial or $1,544.00 * 42 LrevisionMastoidectomy70T -- infant -- antrotomy $1,000.00 42 L71T -- simple -- complete any age $1,000.00 42 L72T -- radical -- classical -- revision $1,070.00 42 L74T -- revision -- same surgeon $1,000.00 42 L75T -- revision -- different surgeon $1,000.00 42 L76T -- revision -- with musculoplasty, add to 72T, $124.10 42 L74T, 75T or 87T77T Review of radical mastoid cavity -- removal $70.00 * 0 Lof cerumen and debris -- unilateralPost-aural fistula78T -- closing $200.00 42 L79T -- with sliding or pedicle graft $400.00 42 L80T -- stapedectomy with prosthesis (fenestration $1,500.00 42 Lof the oval window)81T Stapes mobilization $621.70 42 LSinus thrombosis82T -- operative management with mastoidectomy $861.40 42 L83T Tympanotomy, exploratory (internal) (not $467.60 42 Lpaid in addition to inner ear surgery)283T Tympanotomy with ossicular chain $800.00 42 Lreconstruction84T Myringoplasty -- per canal approach only $492.20 42 L85T Tympanoplasty with widening of external $990.80 42 Lauditory canal and exploration of atticwith or without antrotomy86T -- with ossicular reconstruction $1,200.00 42 L87T -- with radical mastoidectomy $1,800.00 42 L88T Myringotomy with insertion of tube (total $172.30 42 Lcare)NoseAntrum -- puncture and/or irrigation90T -- unilateral diagnostic or therapeutic $50.00 * 0 L92T Anterior packing for epistaxis (unilateral $92.00 * 0 Lor bilateral)93T Post nasal packing -- unilateral or bilateral $246.10 * 0 LSMA FEE GUIDE - T3 - April 1, 2012

SECTION T:OTOLARYNGOLOGYFeeAnae292T Post nasal packing -- bilateral $50.00393T Epistaxis, for anterior packing and post $400.00 * 0 Lnasal packing (unilateral or bilateral)Foreign body removal94T -- simple $57.20 * 0 L95T -- complicated -- general anaesthetic $203.30 * 10 LPolyp removal96T -- single -- in office $200.00 * 10 L296T -- in operating room $203.30 * 10 L97T -- multiple -- unilateral -- in operating $221.50 10 Lroom98T -- choanal $203.30 10 L-- electrocoagulation -- unilateral orbilateral99T -- per treatment $42.80 0 L-- maximum fee for full treatment $171.20Choanal atresia105T -- emergency treatment in newborn, $246.10 0 Ltransnasal procedure and insertionof tube106T -- repair -- anterior nasal approach -- $600.00 42 Munilateral107T -- repair -- transpalatal approach $1,000.00 42 M108T -- choanal dilation $92.00 * 0 L109T Cauterization of nose -- general $200.00 * 0 LanaestheticSeptum cauterization (unilateral or bilateral)110T -- chemical $40.00 * 0 L111T -- electro-cautery or diathermy $200.00 * 0 L112T Submucous resection $400.00 42 L113T Septoplasty -- utilizing transfixion incision $600.00 42 Mwith mobilization of cartilagenous septumSeptal dermoplasty114T -- septum only $900.00 42 L115T -- septum, floor and lateral wall $900.00 42 LSinus -- unilateral operation-- maxillary antrum116T -- radical (Caldwell-Luc, etc.) $900.00 42 M117T -- radical with closure of oral fistula $910.60 42 M118T -- intranasal $215.10 42 MSMA FEE GUIDE - T4 - April 1, 2012

SECTION T:OTOLARYNGOLOGYFeeAnae-- ethmoidectomy119T -- external $1,000.00 42 M520T -- intranasal -- anterior or complete $308.20 42 L122T -- frontal -- external -- trephine $600.00 42 M123T -- obliteration -- osteoplastic flap $1,181.30 42 Mwith fat or similar graft124T -- obliteration -- removal of anterior $873.10 42 Mwall and floor125T -- including either ethmoid and/or $1,040.00 42 Msphenoid126T -- intranasal $350.00 42 M127T -- sphenoid -- intranasal $350.00 42 MTransphenoidal exposure of pituitary forhypophysectomy see Section K, Spine Surgery.Transantral Orbital Decompression128T -- unilateral $1,000.00 42 M129T -- bilateral $1,641.40 42 MTurbinate130T -- cauterization -- cautery or $124.10 * 0 Ldiathermy (unilateral or bilateral)131T -- resection -- partial $160.50 10 M132T -- submucous resection of $246.10 10 M450T -- sinuscopy -- unilateral or bilateral $70.00 D LThroat and MouthFrenectomy139T -- under general anaesthesia $200.00 * 10 M138T -- without anaesthesia $86.00 * 10 LAbscess -- incision and drainage with scalpel140T -- peritonsillar or retropharyngeal $500.00 * 10 M142T Adenoidectomy $500.00 42 M145T Tonsillectomy (with or without adenoidectomy) $600.00 * 42 M147T Post T & A hemorrhage -- surgical treatment $1,000.00 * 42 M149T Post T & A hemorrhage -- treatment by $328.00 42different surgeonEndoscopic165T -- removal of foreign body from larynx $600.00 42 MLaryngoscopy-- direct173T -- diagnostic $203.30 * D L174T -- with biopsy $400.00 D M175T -- with benign tumor removal or cord $400.00 42 MstrippingSMA FEE GUIDE - T5 - April 1, 2012

SECTION T:OTOLARYNGOLOGYFeeAnae275T -- with microscope - with biopsy or cord stripping $406.50 42 L171T Intubation -- for laryngeal obstruction $600.00 * 0 M176T Hypopharyngeal -- removal of foreign body $200.00 * 0 M177T Tracheostomy $712.00 42 M178T Complete change of tracheostomy tube or $200.00 * 0 LBlom Singer prosthesisMiscellaneous192T Arytenoidopexy or arytenoidectomy $910.60 42 M193T Total laryngectomy $2,400.00 42 H194T Partial laryngectomy -- not laryngofissure $1,852.20 42 H195T Laryngofissure $1,600.00 42 M196T Anterior or lateral pharyngotomy $910.60 42 M197T Total maxillectomy with or without orbital $1,852.20 42 Mexenteration198T Transoral cricopharyngeal myotomy $1,200.00 42 M199T Transoral cricopharyngeal myotomy $200.00 42 Mwith another procedure, addTympanic neurectomy200T -- unilateral $621.70 42 M201T -- bilateral $1,138.50 42 M300T Laryngoscope or nasal sinuscope tray fee -- for $24.00 *cleaning and maintaining endoscopic instruments(can be paid in addition to the following officeprocedures only 173T, 174T, 175T, 450T)SMA FEE GUIDE - T6 - April 1, 2012

SECTION V:LABORATORY MEDICINELaboratory MedicineLaboratory services in lists 1, 2 and 3, provided outside of a hospital orany other facility in which laboratory costs are funded by the SaskatchewanHealth, Regional Accountability Branch are insured as defined in the lists:PhysicianPayment Approved ForPathologist Lists 1, 2, 3Physician with a registeredLaboratory Technician Lists 1, 2Other Physicians Lists 1"Pathologist" -- means a specialist whose name appears on the list ofspecialists maintained by the College of Physicians and Surgeons ofthe Province of Saskatchewan as being a pathologist.List 1Classification: DiagnosticFee14V HAEMOGLOBIN $8.6015V HAEMATOCRIT or PCV $7.0031V BLOOD SUGAR -- diagnostic stick --whole blood $7.0032V BLOOD SUGAR -- serum -- machine read (when done on an $9.20Ames seralyzer or a similar machine)59V URINALYSIS -- dipstick $7.4060V URINALYSIS -- complete -- dipstick and microscopic $9.2062V TEST FOR PREGNANCY -- any method $17.2070V EXAMINATION OF SLIDE FOR TRICHOMAS, $9.20YEAST, SCALES(Lab Licence not required to perform this service.)80V OCCULT BLOOD $9.2090V MICROALBUMIN TESTING max one per year per $15.00patient (for diabetic patients with negative albumin only)urine dipstickNote:Tests performed on the Ames Glucometer or similar equipmentproviding blood surgar readings on whole blood should be billedas service code 31V Blood sugar -- diagnostic stick, not as 32V.List 2Classification: DiagnosticThe following services are insured when provided by a physician or bya registered laboratory technologist or a certified combined laboratoryand x-ray technician in a medical laboratory which holds a Category IIlicence issued pursuant to The Medical Laboratory Licensing Act .A Category II laboratory must employ a registered laboratory technologistor certified combined laboratory and x-ray technician.Fee12V BLOOD PROFILE (includes Hb, WBC, Smear and Differential) $20.40(not to be used when any portion of the result is obtained bythe use of automated or semi-automated analyzers)14V HAEMOGLOBIN $8.6015V HAEMATOCRIT OR PCV $7.0017V SEDIMENTATION RATE (ESR) $7.0018V SMEAR WITH DIFFERENTIAL COUNT $9.8019V WHITE BLOOD CELL COUNT $6.00904V AUTOMATED OR SEMI-AUTOMATED HAEMATOLOGY $17.80PROFILE, COUNTS and INDICIES(includes haemoglobin, RBC, WBC, haematocrit, MCH,MCHC, and MCV, when performed)27V BLOOD UREA NITROGEN -- SERUM -- machine read $6.20(when done on an Ames seralyzer or a similar machine)SMA FEE GUIDE - V1 - April 1, 2012

SECTION V:LABORATORY MEDICINEFee29V BLOOD UREA NITROGEN -- DIAGNOSTIC STICK -- whole blood $4.2031V BLOOD SUGAR -- DIAGNOSTIC STICK -- whole blood $7.0032V BLOOD SUGAR SERUM -- machine read (when done on $9.20an Ames seralyzer or a similar machine)33V BLOOD GLUCOSE TEST or GLUCOSE TOLERANCE $10.80TEST (including urine test), per unit59V URINALYSIS -- dipstick $7.4060V URINALYSIS -- complete -- dipstick and microscopic $9.2062V TEST FOR PREGNANCY -- any method $17.2070V EXAMINATION OR SLIDE FOR TRICOMONAS, YEAST, $9.20SCALES(Lab Licence not required to perform this service.)80V OCCULT BLOOD $9.20512V PROTHROMBIN -- Quick's one stage prothrombim time $11.20with control627V SPOT TEST FOR MONONUCLEOSIS $16.6090V MICROALBUMIN TESTING -- max one per year per $15.00patient (for diabetic patients with negative albumin only)urine dipstickNote:Tests performed on the Ames Glucometer or similar equipmentproviding blood surgar readings on whole blood should be billedas service code 31V Blood sugar -- diagnostic stick, not as 32V.List 3Classification: Diagnosticpecialist in Pathology1. The following services are insured when provided in a medical laboratorywhich holds a Category III or Category IV licence issued pursuant to TheMedical Licensing Act. A Category III laboratory is a laboratory outside ofa hospital which is supervised by a pathologist. A Category IV laboratoryis a satellite laboratory afiliated with a Category III laboratory whosemanager is responsible for the satellite laboratory.Payment includes both the technical and professional components unlessotherwise specificed.2. Supervision by a pathologists means that he shall:(a) live in the town or city where the laboratory is located;(b) personally visit the laboratory at least three times a week;(c) supervise the recruitment and work of the laboratory personnel andthe purchasing of equipment and supplies;(d) be available at all times for consultation;(e) accept responsibility for the procedures used in the work of thelaboratory; and(f) if the specialist is hospital-based, then his supervision of a non-hospitallaboratory should be restricted to one such laboratory.The listed payment for a service applies to the provision of the service byany method unless otherwise specified in the description of the service.Pathologist Assessment65A Assessment $55.20-- includes all visits necessary, history and examination,review of laboratory and/or other data, written submissionof the consultant's opinion and recommendations to thereferring doctor and advise to the patient as required.-- only payable to physician providing a surgical biopsy (standardassessment rule apply)SMA FEE GUIDE - V2 - April 1, 2012

SECTION V:LABORATORY MEDICINESpecialist in PathologySpecimen Collection and Referral751V Phlebotomy, venipuncture $47.40752V Phlebotomy, pediatric (0 to 6 years) $71.40771V Referral - Blood $24.20770V Referral - urine $24.20772V Referral - other $30.80756V Referral - TDG - blood (transfer of dangerous goods) $75.00757V Referral - TDG - urine (transfer of dangerous goods) $75.00758V Referral - TDG - other (transfer of dangerous goods) $75.00ChemistryBlood Gases111V Blood gases (pH, p02, pC02, 02 saturation) $16.60112V Blood gas (pH only) $11.80113V Blood gas and metabolytes - (pH, p02, pC02, 02 saturation, $24.40sodium, potassium, chloride, glucose, lactate)114V Blood gas and metabolytes - pH, p02, pC02, 02 saturation, $26.20sodium, potassium, chloride, glucose, lactate and ionizedcalcium118V CoOximetry (any single test) $11.80119V CoOximetry (methemoglobin, carboxyhemoglobin) $15.00120V Blood gas, metabolytes and CoOximetry (pH, p02, pC02, $32.4002 saturation, sodium, potassium, chloride, glucose, lactate,ionized calcium, methemoglobin, carboxyhemoglobin,oxyhemoglobin, hemoglobin-arterial)121V Ionized Ca whole blood $11.80122V Ionized calcium - serum $11.80Routine130V Specimen may be serum/plasma/urine/fluids $11.80-- single analyte131V For each additional analyte performed on the same specimen $1.60from the following menu add - albumin, alk phos, ALT,amylase, AST, total bili, direct bili, calcium, creat CK,CKMB, chloride, TC02, glucose, GGT, ethanol, totalprotein, magnesium cholestrol, triglyceride, HDL chol,iron + total iron binding, uric acid, sodium, potassium, LD,lactate, phos, urea, amonia, acetaminaphen, salicylateUrinalysis/Urine Testing132V Routine urinalysis includes: bilirubin, glucose, hemoglobin, $14.00ketones, leukocytes, nitrates, pH, protein, specific gravity& urobilinogen133V Urine microscopy $11.80134V Myoglobin urine $44.20135V Occult bld (Stool/gastric) $11.80136V Osmolality urine/serum $40.20137V Ketones, reducing substances (urine/feces) $4.00138V 24-hour urine, creatinine clearance $33.40139V 24-hour urine, total protein $31.80141V Alb/Creat Ratio $78.60433V Microalbumin - by automated method $32.60140V Pregnancy test HCG (urine or serum) $46.00Chemistry - Immunology/Rheumatology151V A 1 antitrypsin $32.60152V C3 $32.60153V C4 $32.60162V Ceruloplasmin $32.60155V C-reactive protein $32.60240V Electrophoresis (serum) $78.60156V Electrophoresis CK $78.60157V Electrophoresis CSF/urine $98.60158A IgA $24.60159V IgG $32.60SMA FEE GUIDE - V3 - April 1, 2012

SECTION V:LABORATORY MEDICINESpecialist in Pathology161V IgM $32.60163V Immunofixation (serum/CSF/urine) $191.00630V Rheumatoid factor $32.60166V Transferrin $32.60167V Cryoglobulins $49.00Chemistry - Endocrinology and TherapeuticDrug Monitoring171V For any single analyte ordered on the same specimen $21.80from the following group172V For each additional analyte ordered from the following $7.00group add: alpha fetoprotein, carbazamepine, CEA,digoxin, ferritin, follicle stimulating hormone, gentamicinleutenizing hormone, phenobarbital, phenytoin, prolactin,serum beta HCG quantitative, theophylline, tobramycin,troponin 1, valproic acid, vancomycin173V Estradiol $59.80174V Free T3 $16.20175V Free T4 $16.20270V TSH $16.20271V TSH (Free T4 reflexed) $22.00181V TSH (Free T4 & Free T3 reflexed) $28.00182V Amikacin $27.20183V Cortisol $27.20185V Cyclosporine $38.00186V Methotrexate $27.20187V PSA $21.80188V Secobarbital, phenytoin, amobarbital, butalbarbital, $109.00pentobarbital, phenobarbital (unine/serum) (whendone as a panel of six)189V Tacrolimus $43.40190V Thiopental $81.40203V Toxicology screen (serum or urine) $189.00Chemistry - Miscellaneous204V B2 microglobulin $27.20205V Bili aminiotic - B12/RBC folate - see hematology section $75.00302V Calculus analysis $59.80142V Carotene $136.00206V Chylomicrons (refridge & visual) $43.40207V Chymex $81.40208V Cryofibrinogen $81.40168V Cryoglobulin $49.00209V Ethanol, isopropanol, methanol (when done as a $87.00panel of three)210V Ethylene glycol $87.00211V Fat globule (prep, stain, interp) $109.00412V Fecal fat assay $299.00212V FEP assay $103.00213V Gastric analysis $32.40214V Glucose by glucose meter $14.00215V Haptoglobin $32.60216V Hemoglobin A1C - iron/iron binding/%saturation - see $23.60hematology section249V Lithium $22.00217V LS/PG on amniotic fluid $271.00338V Melanin $54.20202V Methemalbumin $114.00425V Mucin $27.20218V pH - ph meter (fluid) $11.80219V Phenylalanine $81.40221V Plasma hemoglobin $81.40349V Porphobilinogen scrn $49.00222V Porphyrin screen (feces/urine/serum) $59.10SMA FEE GUIDE - V4 - April 1, 2012

SECTION V:LABORATORY MEDICINESpecialist in Pathology224V Prealbumin $32.60225V Pregnancy test/HCG in serum $46.00227V Sweat chloride analysis (does not include specimen $32.40collection418V Trypsin $59.80229V Xylose $43.40Chemistry - Allergy235V IgE $137.00236V Food mix screen $137.00237V Inhalant screen IgE $137.00238V For each additional specific allergen ordered with $19.00total IgE or a screen, add239V For each allergen, if ordered individually - some common $137.00allergens are: dog dander, dust, milk, yellow hornet,honney bee, peanutHaematology - Routine422V CBC 8 parameters + histograms, three or five part diff $25.00423V CBC 8 parameters or less (Hb, Hct, RBC, WCB, MCV, $15.00MCH, MCHC + platlets)Miscellaneous251V B12 $21.80253V Cell count and diff CSF $105.00434V Erythrocyte sedimentation rate $20.00464V Estimate - platelet/WBC $15.00254V RBC folate $54.20180V Iron, TIBC and % saturation $25.40255V Manual differential $55.20257V Manual hemoglobin $55.20476V Manual WBC $31.20259V Monotest $31.20260V Morphology $15.00470V Reticulocyte count $45.40494V Blood parasites (malarial & others) $110.00261V Bone marrow - assist, stain, differential, iron $462.00262V Bone marrow - for each additional 500 cells counted, add $99.60263V Bone marrow - for each additional slide stained $99.60265V Buffy coat preparation $80.20481V Cell count and diff $90.40266V Cytospin $35.20267V Eosinophil smear (sputum) $40.20268V Eosinophil smear (urines) $75.20550V Esterase, iron, peroxidase, sudan black, TRAP $101.00274V Fluid crystals $31.20497V Heinz bodies (direct) $75.20346V Hemoglobin pigments (qual) $60.20275V Hemolysate preparation $85.60276V Iron stain hematology $25.00277V Luik, Alk phos score $182.00278V Hemosiderin - urine $31.20Haematology - Coagulation279V PT/NR & aPTT $22.60280V Prothrombin time/INR $20.00281V aPTT $20.00282V DDIMER - automated $184.00283V Factor assays (each) $132.00506V Fibrinogen $20.00Haematology - Flow Cytometry284V CD4/CD8 $734.00285V CD34-Peripheral bld $541.00287V CD34-apheresis $720.00SMA FEE GUIDE - V5 - April 1, 2012

SECTION V:LABORATORY MEDICINESpecialist in PathologyTransfusion Medicine560V ABO & RH typing (group & type) $85.80563V Antibody screen $77.20289V Antibody panel $129.00290V Each additional panel $129.00291V Antigen typing $77.20600V Direct antiglobulin test (coombs & fractionation) $94.40559V Cross match (group & type, antibody screen & 2 units $189.00of packed cells)293V Each additional unit of packed cells $34.20295V HLA typing (ABC/DR typing) $2,392.00Microbiology - Routine297V Blood C & S for bacteria &/or yeast - automated $87.40690V Blood C & S for bacteria &/or yeast - manual $157.00299V Cervix C & S $87.00300V CSF C & S $134.00301V Dermatophyte culture $306.00305V Direct Gram Stain Only $66.40306V Effluent Culture $117.00307V Enviromental Culture $65.60309V Fluids C & S $170.00311V Fungal C & S $306.00312V Lower Respiratory CBS with Gram Stain $121.00724V Microscopic Exam for Fungus $46.00313V Miscellaneous C & S $184.00314V MRSA Culture $106.00731V Parasite examination - pinworm paddle $46.00725V Parasite examination - skin scrapings $92.20317V Parasite examination - stool - full O & P workup $200.00318V Parasite examination - stool - giardia/crytosporidium screen $46.00319V Parasite examination - trichomonas $46.00729V Parasite examination - urine $97.20321V Pneurnocystis examination $242.00322V Stool for C & S $104.00323V Stool for C. difficile toxin $56.20324V Streptozyme screen $35.60325V Throat C & S $56.20326V Ureaplasma urealyticum testing $64.00327V Urethra C & S $87.00329V Urine C & S $51.20331V Vaginal or vaginal/rectal swab for group B strep $67.00333V Vaginal swab for bacterial vaginosis examination $66.40334V VRE screen $67.40335V Wound culture - deep site $170.00337V Wound culture - surface site $139.00Microbiology - TB344V Bronchial washing TB culture $426.00345V CSF TB culture $405.00347V Fluid TB culture $465.00351V Gastric washing TB culture $327.00352V PCR for M. tuberculosis $474.00242V PCR for mycobacteria species $474.00722V Smear only $189.00354V Sputum TB culture $465.00355V Stool TB smear $189.00356V Miscellaneous TB culture $405.00357V Tissue TB culture $465.00358V Urine TB culture $368.00Microbiology - Virology359V CMV antigenemia $830.00360V CMV IgG $131.00361V EBV serology (EBNA, VCA IgM, VCA IgG) - if ordered individually $116.00SMA FEE GUIDE - V6 - April 1, 2012

SECTION V:LABORATORY MEDICINESpecialist in Pathology363V If added to an existing order -- add $43.80368V EBV EA - if ordered individually $290.00369V - if added to an existing order -- add $219.00370V Hepatitis testing - single marker $145.00371V For each additional marker added to order -- add $72.60Includes the following list of markers: Hepatitis A Antibody,Hepatitis A IgG, Hepatitis A ImG, Hepatitis B Core Antibody,Hepatitis B Core IgM, Hepatitis B Surface Antibody,Hepatitis B Surface Antigen, Hepatitis C Antibody373V Herpes antibody $131.00374V Mycoplasma pneum. AB $131.00375V Parvovirus serology (B19 - IgG & IgM) $320.00376V Rubella IgG antibody $116.00377V Rubella IgM $102.00379V Toxoplasma IgG $102.00383V Toxoplasma IgM $102.00384V Varicella IgG antibody $131.00385V Chlamydia culture $278.00386V Respiratory specimen for viruses by direct fluorescent $407.00antibody tests387V Rotavirus antigen test $116.00388V Viral culture - CSF $423.00389V Viral culture - Eye $439.00390V Viral culture - genital $285.00391V Viral culture - miscellaneous $658.00392V Viral culture - respiratory $481.00393V Viral culture - skin $515.00394V Viral culture - stool $522.00395V Viral culture - tissue $685.00396V Viral culture - urine $405.00Microbiology - DMP398V Chlamydia trachomatis PCR $311.00399V Hepatitis C PCR $683.00400V Herpes simplex virus PCR $384.00401V Pertussis PCR $373.00402V Varicella PCR $244.00CytologyCytology - Gyne403V Cytology - gyne specimen - 1 slide (PAP) $48.80405V Cytology - gyne specimen - each additional slide (PAP) $16.40Cytology - Med407V Fine needle biopsy - (cytospin. Handling. 1 slide) $568.00409V Fluid for cells (1 slide) $228.00411V Sputum for cells (1 slide) $216.00413V Urine for cells (1 slide) $228.00415V Urine for cells -- each additional slide $51.60SMA FEE GUIDE - V7 - April 1, 2012

SECTION W:DIAGNOSTIC ULTRASOUNDMultiple Procedures -- are paid at 100% of the listed units for each procedure.TechnicalTechnical Interpretation andHead and Neck Component Component Interpretation11W Echoencephalography (midline $59.00 $45.00 $104.00and ventricular size)12W Thyroid sonography $97.40 $53.50 $150.9013W With 7.5 or 10 mhz. transducer $125.50 $53.50 $179.0016W Biometry for measuring axial length $54.60 $40.00 $94.60- unilateral(second eye not billable if done forcomparison purposes)17W Ophthalmic sonography for diagnostic $52.00 $37.00 $89.00examination of the posterior segment- unilateral(second eye not billable if done forcomparison purposes)14W Transfontanel neonatal brain sonography $107.70 $59.30 $167.00Chest20W Echocardiography, M-mode $124.20 $77.00 $201.2021W ultrasonically guided $92.40 $75.60 $168.00-- pericardiocentesis, or-- thoracocentesis22W Sonography for pleural effusion $77.20 $27.80 $105.0023W Sonography for breast mass $91.00 $56.00 $147.00(per breast)Abdomen30W Sonography for kidneys, liver, $179.00 $101.00 $280.00pancreas, gall bladder, spleen,aorta, and related structures31W Renal sonography -- independent $106.80 $74.20 $181.00study only32W Ultrasonically guided biopsy or $96.40 $54.50 $150.90cyst aspirationObstetrics and Gynaecology40W Obstetrical scan -- complete $167.60 $98.40 $266.00(includes pregnancy diagnosis,foetal age determination andplacenta localization)47W --for twins (not to be billed before 16 weeks) $163.50 $98.50 $262.0048W --for triplets or greater (not to be billed $242.00 $162.00 $404.00before 16 weeks)41W Obstetrical scan -- limited $87.80 $51.20 $139.0042W Sonography for I.U.C.D. $97.40 $59.90 $157.30localizationSMA FEE GUIDE - W1 - April 1, 2012

SECTION W:DIAGNOSTIC ULTRASOUNDTechnicalTechnical Interpretation andComponent Component Interpretation43W Sonography for pelvic mass $145.60 $78.40 $224.00diagnosis45W Transvaginal ultrasound study add to 40W or 43W $68.20 $36.80 $105.00149W Nuchal translucency screening -- first trimester $80.00 $50.00 $130.00(in an approved facility, only physicians designatedby the SMA Tariff Committee as eligible ) -- oneper pregnancy150W - each additional foetus $60.00 $37.50 $97.5049W Transvaginal ultrasound study as an $135.20 $72.80 $208.00independent procedure -- initial(Serial studies for infertility are uninsuredand not billable. Follicle tracking forinsured services is payable as 49W for thefirst exam and 449W for subsequentexams within 22 days).449W Transvaginal ultrasound follicle tracking $80.00 $47.00 $127.00follow-up study -- subsequent examwithin 22 days44W Ultrasonically guided $97.40 $59.90 $157.30amniocentesis46W Biophysical profile of fetus (not to be billed $147.70 $103.80 $251.50before 28 weeks) max of 1 per day446W Biophysical profile per additional multiple $93.80 $60.20 $154.00fetus (not to be billed before 28 weeks)Doppler Studies50W Flow studies including arterial $122.80 $55.20 $178.00or venous or foetal monitoringor shunt assessment, etc.max of 1 per day54W peripheral venous (per limb) $214.50 $81.50 $296.0051W - each additional foetus $89.40 $40.60 $130.00Miscellaneous60W Transrectal ultrasonography of $122.00 $77.00 $199.00prostate62W Ultrasonography of testicles $97.30 $56.70 $154.0070W Localized soft tissues, popliteal $109.40 $61.60 $171.00fossa or hypertrophic pyloricstenosis71W Rotator cuff or congenital $148.80 $73.20 $222.00dislocation of hip72W Ultrasonography of parotid glands $81.30 $56.70 $138.00or similarSMA FEE GUIDE - W2 - April 1, 2012

SECTION X:DIAGNOSTIC RADIOLOGYFee9X Special review of x-rays by Radiologist $140.00with written report to referringphysician(s) by reportClassification: Diagnostic1. A radiologist should only bill for a service where he has performed theprocedure personally or the technical component was performed byqualified staff for whom he assumes responsibility and provides dailysupervision.2. The billing for diagnostic x-rays of any one region includes payment fora sufficient number of films to establish a diagnosis in the average case.Payment includes the customary media and its administration, but notthe specialist clinic procedures listed in Section A of the PaymentSchedule for which an additional payment may be made.3. Multiple Diagnostic Procedures -- may be billed at 100 percent of the listedpayment for each procedure both from Section X and Section A.TechnicalTechnical Interpretation andComponent Component InterpretationHead100X Skull $59.00 $25.00 $84.00101X Nasal sinuses $57.50 $27.00 $84.50102X Mastoids $64.00 $32.00 $96.00103X Facial bones and/or zygoma $57.50 $28.50 $86.00104X Nasal bones $42.50 $14.50 $57.00105X Salivary duct $44.00 $26.00 $70.00106X Internal auditory meati $58.00 $21.50 $79.50107X Mandible $52.00 $20.00 $72.00108X Temporomandibular joints $57.50 $24.00 $81.50109X Eye (without localization) $49.00 $23.00 $72.00110X Sella turcica $43.50 $21.50 $65.00120X Pantomography - not insured for $38.00 $25.50 $63.50routine dental careTeeth121X -- isolated area $11.60 $9.60 $21.20122X -- quarter set $20.00 $11.40 $31.40123X -- half set $24.60 $13.90 $38.50124X -- full set $37.60 $20.80 $58.40125X Eye -- Sweet (or equivalent) $69.50 $42.50 $112.00localization for foreign body ineye or orbitSMA FEE GUIDE - X1 - April 1, 2012

SECTION X:DIAGNOSTIC RADIOLOGYTechnicalTechnical Interpretation andComponent Component InterpretationSpine and Pelvis130X Cervical $84.00 $31.00 $115.00131X Thoracic $67.00 $25.00 $92.00132X Lumbar $84.00 $31.00 $115.00133X Sacro-iliac joints $42.00 $24.50 $66.50134X Sacrum and coccyx $42.00 $24.50 $66.50135X Scoliosis survey (limited) $38.50 $19.00 $57.50136X Oblique views of spine, add $32.00 $15.50 $47.50137X Lumbar spine with flexion and $78.00 $36.00 $114.00extension138X Cervical spine with flexion and $78.00 $36.00 $114.00extension140X Scoliosis survey -- full $66.00 $36.00 $102.00141X Myelogram $177.00 $100.00 $277.00142X Discogram $176.20 $91.80 $268.00143X Pelvis $44.50 $20.00 $64.50144X Pelvis and one or both hips $77.20 $28.80 $106.00145X Smith-Peterson pinning $138.60 $79.40 $218.00Thorax150X Chest $65.00 $28.00 $93.00151X Thoracic inlet $37.00 $17.50 $54.50152X Ribs $48.50 $19.00 $67.50153X Clavicle $42.50 $16.50 $59.00154X Sternum or sterno-clavicular $42.50 $17.50 $60.00joints157X Bronchogram (unilateral) $87.00 $40.00 $127.00158X Chest films with fluoroscopy $52.50 $34.00 $86.50159X Heart survey and/or cardiac $53.60 $21.40 $75.00pacemaker evaluationExtremities160X Acromio-clavicular joint $42.50 $17.50 $60.00161X Shoulder $46.00 $19.60 $65.60361X Shoulder -- specialty view -- 4 (views) $59.50 $21.00 $80.50unilateral162X Humerus $42.50 $16.50 $59.00163X Elbow $42.50 $16.50 $59.00164X Forearm -- radius and ulna $42.50 $16.50 $59.00165X Wrist $42.50 $16.50 $59.00166X Carpals $42.50 $16.50 $59.00167X Hand $52.80 $22.60 $75.40168X Scapula $42.50 $18.00 $60.50170X Femur $42.50 $18.00 $60.50171X Knee $52.80 $22.60 $75.40172X Tibia and fibula $42.50 $18.00 $60.50173X Ankle $50.60 $21.80 $72.40SMA FEE GUIDE - X2 - April 1, 2012

SECTION X:DIAGNOSTIC RADIOLOGYTechnicalTechnical Interpretation andComponent Component Interpretation174X Tarsus $50.60 $21.80 $72.40175X Forefoot $42.50 $18.00 $60.50176X Os calcis $42.50 $18.00 $60.50190X Single digit, same hand or foot $40.00 $17.50 $57.50191X Digits, same hand or foot $42.50 $17.50 $60.00192X Orthoroentgenograms $42.00 $22.00 $64.00Bone Survey193X Bone survey $116.00 $48.00 $164.00194X Joint survey $116.00 $48.00 $164.00195X Wrist -- four views $44.50 $23.50 $68.00196X Knee -- four views $62.30 $26.50 $88.80197X Skeletal survey -- infant $78.00 $35.00 $113.00Abdomen200X Single film of abdomen (K.U.B.) $36.00 $17.50 $53.50201X Acute abdomen survey with erect $52.00 $30.50 $82.50and/or lateral viewsGastro-Intestinal Tract210X Oesophagus $72.50 $31.50 $104.00211X G.I. Series $134.00 $65.00 $199.00212X Small bowel study $104.00 $40.00 $144.00213X Colon -- enema $163.50 $71.50 $235.00214X Colon -- double contrast enema $227.50 $88.50 $316.00215X Fluoroscopy for position of tube $29.00 $26.40 $55.40in abdomen216X Hypotonic duodenography $73.20 $42.80 $116.00217X Double contrast G.I. with $136.50 $40.00 $176.50glucagonBiliary System220X Cholecystogram $62.00 $28.00 $90.00Cholangiogram221X -- intravenous $161.80 $61.20 $223.00222X -- operative $112.40 $49.60 $162.00223X -- post-operative (T-tube) $100.00 $47.00 $147.00224X -- transhepatic, percutaneous $169.00 $71.00 $240.00Urinary System228X Percutaneous renal cystography $46.60 $16.40 $63.00229X Intravenous pyelogram $141.60 $38.40 $180.00(hypertensive survey)230X Cystogram $73.20 $26.80 $100.00Pyelogram231X -- intravenous $183.80 $47.20 $231.00SMA FEE GUIDE - X3 - April 1, 2012

SECTION X:DIAGNOSTIC RADIOLOGYTechnicalTechnical Interpretation andComponent Component Interpretation232X -- retrograde $57.80 $16.10 $73.90233X I.V.P. -- with voiding $154.40 $49.60 $204.00cystourethrogram234X Voiding cystourethrogram $142.80 $65.20 $208.00235X Drip infusion pyelogram $169.00 $69.00 $238.00239X Urethrogram (retrograde) $58.20 $24.20 $82.40Obstetrics and GynaecologyFoetus240X -- scout film $30.60 $18.60 $49.20241X -- maturity and/or position $30.60 $18.60 $49.20243X Pelvimetry $53.60 $27.80 $81.40244X Utero-salpingogram $57.40 $30.80 $88.20245X Intrauterine blood transfusion $51.60 $27.80 $79.40Miscellaneous -- without contrast media300X Diagnostic Mammography (unilateral) $121.00 $77.00 $198.00(repeats within 42 days by report)312X Repeat mammography for $191.00 $50.00 $241.00radiological localization ofnon-palpable breast lesion301X Soft tissues of the neck $40.50 $15.00 $55.50302X -- Laryngogram $73.60 $39.40 $113.00Planigraphy303X -- first cut $47.60 $19.00 $66.60304X -- each additional cut $17.20 $10.00 $27.20306X Cinefluorograph or videotape $25.70 $31.00307X Cardiac catheterization $64.80 $39.20 $104.00Miscellaneous -- with contrast media320X Fistula or sinus tract $49.20 $17.40 $66.60321X Sialogram $106.40 $58.60 $165.00322X Arthrogram $127.00 $56.00 $183.00323X Lymphangiography -- upper and $271.40 $45.40 $316.80lower extremities, includingpelvis, chest and abdomen324X Dacryocystography $51.60 $26.80 $78.40325X Venogram $98.00 $44.00 $142.00327X Selective cavogram $103.60 $43.40 $147.00328X Azygography $103.60 $43.40 $147.00329X Ventriculogram or encephalogram $103.60 $43.40 $147.00Arteriography330X -- peripheral $103.60 $43.40 $147.00331X -- cerebral $123.00 $57.00 $180.00Aortography332X -- aortic $103.60 $43.40 $147.00SMA FEE GUIDE - X4 - April 1, 2012

SECTION X:DIAGNOSTIC RADIOLOGYTechnicalTechnical Interpretation andComponent Component Interpretation333X -- selective -- coronary, renal, $103.60 $43.40 $147.00mesenteric, bronchial, etc.334X Cardiac angiography $123.00 $57.00 $180.00335X Portogram through umbilical vein $123.00 $57.00 $180.00336X Posterior fossa myelogram $138.00 $54.00 $192.00Specialist inRadiology10X Consultation $120.00-- requires formal referral -- includes all visitsnecessary, history and examination, reviewof radiology and/or other data and writtensubmission of the consultant's opinion andrecommendations to the referring doctor.This code does not apply when the radiologistis only providing information to the patientand/or getting consent for a procedure.Classification: Radiologist Clinical Procedures1. The following procedures are insured services where providedby a radiologist.2. Payment to a radiologist will be made only where theradiologist hasperformed the procedure personally.3. Multiple Diagnostic Procedures are paid at 100 percentof the listed payment.4. Other Multiple Procedures (Codes 600X and greater) -- arepaid using the procedural rules for 0 and 10 day procedures,i.e. could be paid at 75 percent.AngiographyThese codes are for use by Radiologists Only. (Cardiologists will find applicableAngiography in the "A" SECTION).501X Vascular access - for angiography purposes $120.00only -- maximum of 2 per case502X Aortography - for a dedicated Aortogram(s) $123.00only-- maximum of once per case503X Large vessel angiography - for angiograms $140.00of the main cerebral and visceral trunksof the aorta to a maximum of 3 per case504X Extremity angiogram - for visualization of vascular $132.00structures in either arm or leg-- maximum of two per case - one per extremitySMA FEE GUIDE - X5 - April 1, 2012

SECTION X:DIAGNOSTIC RADIOLOGYSpecialist inRadiologyAnaeTransluminal angioplasty600X --peripheral $460.00 0 L601X -- renal $540.00 0 M602X --subclavian artery $470.00 0 M603X -- Aorta or aortic valve $840.00 0 M604X Stent placement following angioplasty of $153.00 0 Lperipheral, renal or subclavian vessels --add toappropriate angioplasty code --each vesselNote: Post-angioplasty care for elective proceduresis included in the payment for 603X.Radiology Clinical ProceduresClinical procedures associated with diagnostic radiology maybe charged in addition to the payments listed in Section X ascodes 100X to 336X.Procedures 600X to 663X may be charged by other physiciansrecognized by the College of Physicians and Surgeons ashaving adequate training in radiology and confining theirpractice to radiology.Selective catheterization of renal veinBy Seldinger technique or cut down.606X --unilateral $144.00 D L607X --bilateral $208.00 D L608X Selective catheter embolization $470.00 0 M609X Intravascular thrombolysis --composite $940.00 0 Lprofessional fee610X --repeats within 48 hours (composite professional fee) $470.00 0 L612X Selective transarterial catherization with $426.00 0 Linfusion613X Azygography $82.20 D L614X Peripheral venography --unilateral $133.00 D L615X Cavography (percutaneous or catheter) $171.00 D L616X Lymphangiography --unilateral including pelvis $162.00 D Labdomin and chest617X Arthrography each $122.00 D L618X Bronchogram --unilateral $103.00 D619X Laryngogram $67.20 D620X Myelography $191.00 D L621X Discography --one or more discs $104.00 D L622X Sialography each $131.00 D L623X Injection of a sinus tract $105.00 D L624X Reduction or attempted reduction of $130.00 0 Lintussusception by barium enemaSMA FEE GUIDE - X6 - April 1, 2012

SECTION X:DIAGNOSTIC RADIOLOGYSpecialist inRadiologyAnae625X Percutaneous cholangiography $260.00 D L626X Percutaneous renal cystography . $97.00 D627X --with alcohol obliteration of renal cyst $156.00 0628X Dacryocystography each $104.00 D629X Portogram through umbilical vein $82.20 D630X Bronchial Brushing $128.00 D631X Pelvic Venography $67.20 D L632X Tube positioning for small bowel study $56.50 D L639X Epidurography $119.00 D640X Lumbar Epidural Venography $162.00 D641X Utereal stent placement via nephrostomy tract $265.00 0 LProcedures under fluoroscopic, C.T. or UltrasonicGuidance642X Percutaneous intrathoracic biopsy $235.00 D L643X Percutaneous intra-abdominal biopsy $235.00 D L644X Percutaneous intra-abdominal drainage $352.00 0 L645X Percutaneous biliary drainage $550.00 0 L646X Change of drainage tube in relation to procedures $121.00 0644X, 645X, 647X, 650X, and 651X647X Percutaneous nephrostomy with nephrogram $600.00 0 L648X Manipulation of peritoneal dialysis catheter $112.00 0649X Transjugular liver biopsy $460.00 0650X Percutaneous gastrotomy $335.00 0 L651X Percutaneous jejunostomy $375.00 0 L652X Percutaneous insertion of Vena Cava filter $310.00 0653X Fallopian tube cannulation and dilatation --with $252.00 10 Lselective salpingography, unilateral or bilateral….654X Removal of intravascular foreign body --composite $450.00 0fee655X Transjugular portosystemic shunts (TIPS) $1,080.00 0--composite fee656X Non-palpable breast lesion --needle localization each $130.00 D L657X Stereotactic mammographic guided breast biopsy each $60.00 D L658X Mammographic or ultrasound guided breast biopsy $290.00 D659X Fluoroscopic control of clinical procedures done $18.00 0by another physician per 1/4 hour or major partthereof --technical component660X --professional component $42.00 0661X Percutaneous insertion of Pleural catheter for $175.00 0 Lclosed chest drainage (includes 659X and 660X) each662X Percutaneous intravenous central catheter (PICC) $422.00 0 Lincludes placement, removal, venography andultrasound - composite feeSMA FEE GUIDE - X7 - April 1, 2012

SECTION X:DIAGNOSTIC RADIOLOGYFeeAnae663X Portacath, infusaport, hemocath, Hick-Broviac $374.00 10 Lfor chemotherapy or long-term T.P.N. (PORT)- insertion (composite fee)COMPUTED TOMOGRAPHYHead700X no contrast $82.00701X with contrast $109.00702X with and without contrast $138.00Neck - skull base to thoracic inlet703X no contrast $109.00704X with contrast $123.00705X with and without contrast $138.00Thorax706X no contrast $123.00707X with contrast $138.00708X with and without contrast $164.00Abdomen709X no contrast $123.00710X with contrast $139.00711X with and without contrast $164.00Pelvis712X no contrast $123.00713X with contrast $139.00714X with and without contrast $164.00Spine - cervical, thoracic, or lumbar715X no contrast $116.00716X with contrast $130.00717X with and without contrast $144.00Extremity - arm or leg718X no contrast $109.00719X with contrast $123.00720X with and without contrast $139.00MAGNETIC RESONANCE IMAGING800X Head - Multislice SE $123.00801X Repeat another plane or sequence to max to 3 $54.60Neck (area below the brain and above the chest)802X Multislice SE $123.00803X Repeat another plane or sequence to max to 3 $54.60SMA FEE GUIDE - X8 - April 1, 2012

SECTION X:DIAGNOSTIC RADIOLOGYFeeThorax or Abdomen or Pelvis804X Multislice SE $139.00805X Repeat another plane or sequence to max to 3 $68.90Extremities807X Multislice SE $109.00808X Repeat another plane or sequence to max to 3 $54.60One Spine Zone809X Multislice SE $109.00810X Repeat another plane or sequence to max to 3 $54.60Two adjoining spine zones811X Multislice SE $109.00812X Repeat another plane or sequence to max to 3 $54.60Three adjoining spine zones813X Multislice SE $178.00814X Repeat another plane or sequence to max to 3 $82.00Note:1. Multislice SE refers to a multislice spin echo sequence whetherit is one or two echoes. This applies to a combination of aT1W1 and T2W1. Only one such sequence can be billedper patient at one sitting.2. Repeat refers to another plane or different pulse sequence, but may notexceed three of these.3. Maximum billing will be for four sequences no matter how manyare done.SMA FEE GUIDE - X9 - April 1, 2012

SECTION Y:THERAPEUTIC RADIOLOGYThis Section refers to therapeutic radiology procedures when performedby physicians considered by the Council of the College of Physiciansand Surgeons to be qualified to perform the procedures.TechnicalTechnical Interpretation andVisits Component Component Interpretation7Y Subsequent or follow-up examination after $34.40 $0.00completion of treatment9Y Consultation - major - with written report $87.90 $0.00- superficial radiation therapy19Y - deep or supervoltage therapy $95.00 $95.0029Y - radioisotope therapy $95.00 $95.0010Y Consultation - minor - without written report $17.80 $0.00- superficial radiation therapy11Y - deep or supervoltage radiation therapy $55.80 $55.8012Y - radioisotope therapy $55.80 $55.8013Y - treatment planning, dosage schedule and $184.20 $93.80 $278.00preparation of any special treatment devicefor radiation therapyProcedures1. Those units under Technical Component are to cover the technical costsof administration and measurements. Those units listed underInterpretation Component represent the professional component of thephysicians, i.e. the interpretation and report. The costs of the isotopesor other medications are extra charges.2. Multiple examinations done at the same sitting may be billed at thesum total of the individual items unless otherwise stated.Radiation Therapy100Y Superficial radiotherapy - per treatment $11.90 $11.80 $23.70101Y Hemangioma - complete treatment $23.70 $23.80 $47.50103Y Keloid - complete treatment $23.70 $23.80 $47.50104Y Plantar wart - complete treatment $23.70 $23.80 $47.50105Y Kidney transplant - per course $23.70 $23.80 $47.50120Y Deep radiotherapy (up to 1 Mev energy) $26.10 $26.00 $52.10per treatment122Y Supervoltage radiotherapy (above 1 Mev $55.90 $17.80 $73.70energy) - per treatmentRadioisotope Therapy201Y p32 for polycythemia - per course $112.20 $74.80 $187.00202Y p32 for metastatic bone disease - complete $185.00 $149.00 $334.00treatment203Y For ascites or pleural effusion due to $184.00 $133.00 $317.00malignancy - per course - one sideSMA FEE GUIDE - Y1 - April 1, 2012

SECTION Z:NUCLEAR MEDICINEThis section refers to diagnostic and therapeutic radio-isotope procedures whenperformed by physicians certified in Nuclear Medicine by the Royal Collegeof Physicians and Surgeons of Canada.ProfessionalComponentVISITS7Z Consultation - major - with written report - $130.00Re: radionuclide therapy9Z Subsequent or follow-up examinations after treatment $54.6011Z Consultation - minor - when a Nuclear Medicine procedure $0.00is not performedPROCEDURES1. Those fees under Technical Component are to cover the cost of preparationand administration of the radio-pharmaceutical, technical components of theprocedure and the associated quality control procedures. Those fees underProfessional Component represent the clinical component of the nuclearmedicine physician providing the service, including patient supervision,computer manipulation of data, interpretation and consultation report.2. Multiple examinations done at the same sitting may be billed at the sumtotal of the individual items unless otherwise stated.3. The specialist clinical procedures listed in Section A constitute anadditional charge.4. The professional component of the fee for computer based studies requiresthat the Nuclear Medicine physician performs that portion of the data processingwhich requires clinical knowledge and judgement.5. For single photon emission tomography add 30 percent to the TechnicalComponent and 100 percent to the Professional Components of theappropriate procedure.6. For additional computer analysis for any procedure add 30 percent(per unique analysis) to the corresponding professional fee.TechnicalTechnical Professional andComponent Component ProfessionalEndocrine System100Z Thyroid uptake - single $776.50 $27.50 $804.00101Z Thyroid uptake - multiple $88.20 $41.20 $129.40102Z Thyroid uptake - stimulation or suppression $91.30 $42.70 $134.00105Z Thyroid imaging with uptake $246.00 $95.00 $341.00107Z Thyroid imaging without uptake $150.50 $72.50 $223.00110Z Thyroid carcinoma - metastatic survey $355.00 $145.00 $500.00120Z Parathyroid imaging $383.00 $150.00 $533.00130Z Adrenal imaging - cortex $441.00 $145.00 $586.00131Z medulla $497.00 $145.00 $642.00140Z 131I Therapy for hyperthyroidism, per course excluding $245.40 $54.60 $300.00uptake and scanHaematopoietic, R.E. and Lymphatic Systems150Z Bone marrow imaging - limited study $237.00 $82.40 $319.40151Z Bone marrow imaging - multiple areas or whole body $423.00 $151.00 $574.00160Z Blood or plasma volume - labelled HSA $106.70 $33.30 $140.00161Z Red cell mass - labelled RBC $143.70 $33.30 $177.00162Z Combined plasma volume and red cell mass - dual label $190.60 $95.60 $286.20170Z Red cell survival $146.40 $140.00 $286.40171Z Red cell sequestration $48.40 $238.00 $286.40172Z Red cell survival and sequestration $273.00 $144.00 $417.00175Z Plasma iron clearance rate $882.00 $28.70 $910.70176Z Red cell utilization of iron $253.40 $52.60 $306.00178Z Iron metabolism (clearance, utilization and $323.00 $133.00 $456.00distribution179Z Combined iron metabolism and red cell survival $564.00 $218.00 $782.00180Z Spleen imaging $246.00 $113.00 $359.00181Z Spleen imaging with vascular flow $301.00 $138.00 $439.00SMA FEE GUIDE - Z1 - April 1, 2012

SECTION Z:NUCLEAR MEDICINETechnicalTechnical Professional andComponent Component Professional182Z Lymphoscintigraphy $437.00 $185.00 $622.00183Z Sentinel Node Lymphoseintography $531.00 $266.00 $797.00Gastrointestinal System200Z Liver and spleen imaging $342.00 $151.00 $493.00201Z Liver and spleen imaging with vascular flow $362.00 $164.00 $526.00205Z Hepatobiliary study $437.00 $185.00 $622.00206Z CCK stim/GBEF $272.40 $92.60 $365.00212Z Salivary gland imaging $178.50 $85.50 $264.00213Z repeat with stimulation $91.70 $46.30 $138.00220Z Gastric mucosa imaging $335.00 $157.00 $492.00221Z Gastric emptying time - solid meal $390.00 $226.00 $616.00222Z Gastric emptying time - liquid meal $390.00 $226.00 $616.00225Z Schilling test $150.30 $42.70 $193.00226Z Schilling test with intrinsic factor or pancreatic $150.30 $42.70 $193.00enzymes227Z Schilling test - combined stage I and stage II $184.50 $72.50 $257.00229Z Gastrointestinal blood loss - in vivo imaging $2,432.00 $178.00 $2,610.00230Z Gastrointestinal blood loss - fecal measurement $2,518.40 $91.60 $2,610.00231Z Gastrointestinal protein loss $2,808.40 $91.60 $2,900.00232Z Gastrointestinal absorption - in vitro measurement $3,196.40 $91.60 $3,288.00233Z Gastroesophageal reflux/aspiration $390.00 $226.00 $616.00234Z LaVeen shunt patency $307.00 $107.00 $414.00235Z Bile acid study $2,720.00 $158.00 $2,878.00236Z Oesophageal motility - single $3,067.80 $88.20 $3,156.00237Z - repeat (at same time) $3,503.60 $50.40 $3,554.00238Z 14Carbon breath test $3,300.40 $91.60 $3,392.00Musculo-Skeletal System250Z Bone imaging - limited area $491.60 $82.40 $574.00251Z Bone imaging - multiple areas or whole body $369.00 $151.00 $520.00252Z SI joint analysis $25.10 $25.10255Z Joint imaging - limited area $178.50 $85.50 $264.00256Z Joint imaging - multiple areas or whole body $382.00 $157.00 $539.00260Z Bone densitometry - single photon energy $178.40 $54.60 $233.00261Z Bone densitometry - dual photon energy, per site $253.00 $76.00 $329.00262Z Body Composition - dual photon energy $253.00 $76.00 $329.00270Z Radionuclide synovectomy $273.00 $136.00 $409.00Cardio-Vascular System300Z Determination of ventricular function - gated cardiac $441.00 $263.00 $704.00blood pool (computer based wall motion and ejectionfraction)rest301Z repeat (up to three) per rest $86.00 $190.00 $276.00302Z exercise - per level $145.00 $131.00 $276.00303Z Cardiac Phase Analysis $85.50 $85.50304Z Determination of ventricular function, first pass $402.00 $185.00 $587.00(computer based)305Z Myocardial imaging - regional myocardial perfusion $382.00 $157.00 $539.00rest306Z stress $457.00 $157.00 $614.00307Z Myocardial imaging - infarct avid $313.00 $157.00 $470.00308Z Myocardial imaging - viability $457.00 $157.00 $614.00309Z Cardiac neuroimaging $457.00 $157.00 $614.00310Z Cardiac shunt evaluation (computer based) $307.00 $138.00 $445.00315Z Vascular flow imaging (arterial or venous) $307.00 $138.00 $445.00316Z Venography (labelled RBC) $273.00 $138.00 $411.00320Z Intravascular thrombosis study $245.50 $85.50 $331.00325Z Cardiac output $124.50 $72.50 $197.00SMA FEE GUIDE - Z2 - April 1, 2012

SECTION Z:NUCLEAR MEDICINESMA FEE GUIDE - Z3 - April 1, 2012TechnicalTechnical Professional andComponent Component Professional330Z Supervision - stress for myocardial perfusion $226.00 $226.00exercise331Z pharmacologic $226.00 $226.00Respiratory System350Z Pulmonary perfusion study $362.00 $157.00 $519.00352Z Pulmonary ventilation-multiple projections-aerosol $362.00 $157.00 $519.00353Z Pulmonary ventilation - all phases - gas $390.00 $164.00 $554.00354Z Pulmonary ventilation - technegas $362.00 $157.00 $519.00355Z Combined pulmonary ventilation and perfusion study $477.00 $253.00 $730.00356Z Pulmonary clearance $362.00 $157.00 $519.00357Z Quantitiative analysis - pulmonary function $46.30 $46.30Central Nervous System400Z Brain imaging $354.00 $157.00 $511.00401Z Brain imaging with vascular flow $472.00 $185.00 $657.00402Z Regional cerebral blood flow $477.00 $185.00 $662.00403Z Regional cerebral metabolism $477.00 $185.00 $662.00404Z Cerebral receptor-site imaging $477.00 $185.00 $662.00405Z Cisternography $457.00 $164.00 $621.00408Z Shunt patency study $198.50 $85.50 $284.00409Z CSF leakage (imaging and sample counting) $347.00 $164.00 $511.00420Z Dacrocystography $301.00 $138.00 $439.00Genitourinary450Z Renal imaging $150.50 $85.50 $236.00single image451Z serial images $362.00 $157.00 $519.00452Z Renal imaging with vascular flow $212.00 $113.00 $325.00single static image453Z serial static images $362.00 $185.00 $547.00455Z Renal function study (computer based) $403.00 $226.00 $629.00single radionuclide456Z dual radionuclide $477.00 $253.00 $730.00457Z Renal clearance (computer based) $347.00 $164.00 $511.00458Z Renal - Captopril challenge $403.00 $226.00 $629.00459Z Renal - diuretic $403.00 $226.00 $629.00460Z Residual urine study . $150.50 $85.50 $236.00462Z Ureteral reflux study $211.50 $85.50 $297.00464Z Testricular imaging $246.00 $113.00 $359.00470Z GFR $150.50 $85.50 $236.00471Z ERPF $136.00 $76.00 $212.00480Z Hysterosalpingography $362.00 $164.00 $526.00Miscellaneous500Z Tumor localization (67Ga etc.) $246.00 $113.00 $359.00limited area501Z multiple areas or whole body $390.00 $157.00 $547.00502Z Tumor localization (Immunoscintigraphy) $477.00 $185.00 $662.00multiple areas or whole body503Z Tumor localization (other receptors) $477.00 $185.00 $662.00multiple areas or whole body505Z Inflammation localization (67Ga/Ig etc) $246.00 $113.00 $359.00limited area506Z multiple areas or whole body $390.00 $157.00 $547.00507Z Inflammation localization (WBC) $246.00 $113.00 $359.00limited area508Z multiple areas or whole body $390.00 $157.00 $547.00509Z Inflammation imaging (labelled antibodies, etc.) $477.00 $185.00 $662.00multiple areas or whole body510Z Receptor-site imaging-multiple areas or whole body $477.00 $185.00 $662.00

SECTION Z:NUCLEAR MEDICINETechnicalTechnical Professional andComponent Component Professional511Z Receptor-site imaging - limited area $226.00 $107.00 $333.00Miscellaneous continued514Z Infection imaging (labelled antibiotics, etc.), $235.00 $108.00 $343.00limited area515Z multiple areas or whole body $374.00 $150.00 $524.00516Z Imaging amyloid, etc. limited area $235.00 $108.00 $343.00517Z multiple areas or whole body $374.00 $150.00 $524.00520Z Breast milk assay $150.30 $42.70 $193.00Radionuclide Therapy600Z 32P therapy polycythaemia - per administration $226.20 $74.80 $301.00602Z 131Iodine ablative therapy - per administration $112.20 $74.80 $187.00604Z Metastatic disease - palliative - 99Sr etc. $112.20 $74.80 $187.00606Z Malignant ascites or plural effusion $190.00 $133.00 $323.00per administration608Z Radioimmunotherapy $190.00 $133.00 $323.00per administrationTomography700Z Liver and spleen SPECT $458.00 $330.00 $788.00702Z Hepatic blood pool SPECT $459.00 $344.00 $803.00704Z Bone SPECT $458.00 $330.00 $788.00706Z Joint SPECT $458.00 $330.00 $788.00708Z Gated Cardiac Wall Motion (Blood Pool) SPECT $459.00 $344.00 $803.00710Z Myocardial Perfusion SPECT $458.00 $330.00 $788.00rest711Z stress $458.00 $330.00 $788.00712Z ventricular wall motion/thickening $109.00 $109.00713Z ventricular volumes/ejection fraction $109.00 $109.00714Z Myocardial viability SPECT $459.00 $344.00 $803.00716Z Brain SPECT $458.00 $330.00 $788.00718Z Regional Cerebral Perfusion SPECT $459.00 $360.00 $819.00719Z with acetozolamide etc. $458.00 $322.00 $780.00720Z Cerebral Receptor-site SPECT $459.00 $360.00 $819.00722Z CSF Flow SPECT $458.00 $330.00 $788.00724Z Renal SPECT $458.00 $330.00 $788.00726Z Inflammation SPECT $458.00 $330.00 $788.00728Z Bone Marrow SPECT $458.00 $330.00 $788.00730Z Lymph node SPECT $458.00 $330.00 $788.00732Z Tumor SPECT $458.00 $330.00 $788.00Position Emission Tomography800Z Whole body (planar) $772.00 $249.00 $1,021.00801Z Whole body PET $891.00 $249.00 $1,140.00802Z Partial body PET $772.00 $197.00 $969.00803Z Attenuation correction $126.00 $126.00804Z Specific uptake valves $35.60 $35.60805Z Volume rendering $61.70 $61.70SMA FEE GUIDE - Z4 - April 1, 2012

Hand Surgery AppendixFeeAnaeCodeNervesDecompressionDecompression of entrapment syndrome158K -- median nerve $642.00 42 L159K -- others $1,000.00 42 L169K Transposition of ulnar nerve $904.00 42 LRepair165K Digital nerve suture $800.00 42 L163K Nerve suture (other than digital ) $1,200.00 42 L164K Nerve suture with special techniques to $1,400.00 42 Lovercome gap368K Secondary or delayed nerve repair -- one $300.00 42 Lmonth post injury, add468K Fascicular instead of epineural nerve $535.00 42 Mrepair, addNerve grafting procedures168K -- single cable . $978.00 42 L268K -- multiple cables $1,421.00 42 L162K Exploration of peripheral nerve injury, $864.00 42 Lor neurolysisExcisions - Peripheral Nerve Lesions157K Removal of tumor -- major peripheral $1,000.00 42 Lnerve (e.g. median or ulna)161K Neuroma excision $700.00 42 LTendonsRepair or suture -- flexor tendon696M -- single unless otherwise listed $800.00 42 L697M -- each additional $600.00 * 42 LRepair or suture -- extensor tendon690M -- single hand or foot -- distal to wrist or ankle $550.00 * 42 L-- each additional tendon691M -- foot $300.00 * 42 L692M -- hand $550.00 * 42 L693M -- single -- forearm or leg $500.00 * 42 L-- each additional tendon694M -- leg $55.00 * 42 L695M -- forearm $500.00 * 42 LRepair680M Tendon sheath reconstruction -- insertion of $650.00 42 Lsilastic rod681M -- each additional $357.40 42 L780M Repair boutonniere deformity $393.80 42 LSMA FEE GUIDE - 1 - April 1, 2012

Hand Surgery AppendixFeeAnaeTenolysis and TransfersTransfer or transplant of tendon -- single698M -- distal to elbow, distal to knee $850.00 42 L700M -- each additional $700.00 42 L781M Free extensor tendon graft -- single $600.00 42 L782M -- each additional $410.00 42 L703M Free flexor tendon graft -- single $1,050.00 42 L704M -- each additional $1,033.60 42 LTenolysis705M -- single -- flexor $700.00 42 L706M -- each additional $450.00 42 L725M -- single -- extensor $500.00 42 L726M -- each additional $400.00 42 L707M Lengthening or shortening tendon $600.00 42 L708M Opponens transfer $800.00 42 L709M Intrinsic transplant active or passive $603.50 42 L710M Intrinsic release (Littler) or incision $500.00 42 L711M -- additional fingers $300.00 42 L712M Free fascial graft for reconstuction tendon $600.00 42 Lpulley or repair bowstring tendon - single727M Tenodesis $850.00 * 42 LTenotomy722M -- percutaneous $500.00 * 10 L723M -- open $500.00 * 10 L724M -- each additional (of either 722M or 723M) $300.00 * 10 LBoneFracturesCarpal Bone251M -- closed reduction $295.30 42 L252M -- open reduction $1,050.00 42 L253M -- reduction with external fixation device $750.00 42 LMetacarpal255M -- closed reduction $400.00 42 L257M -- open reduction $700.00 42 L256M Reduction of Bennett's fracture by internal fixation $700.00 42 LPhalanx -- finger or thumb260M -- closed reduction $400.00 42 L262M -- open reduction $700.00 42 L110M Insertion of Kirschner wire or metal pins for $300.00 0 Ltraction or cast fixationSMA FEE GUIDE - 2 - April 1, 2012