Therapeutic Injections and Immunizations

B-26 April 1, 2010

Men–P–ACWY–Meningococcal–Polysaccharide ACWY

8981 single dose ..................................................................................................................................... 8.85

MMR—Measles, Mumps, Rubella

8670 single dose ..................................................................................................................................... 8.85

Pneu–C–7—Pneumococcal Conjugate–7–valent

8681 single dose ..................................................................................................................................... 8.85

Pneu–C–13—Pneumococcal Conjugate–13–valent

8896 single dose ..................................................................................................................................... 8.85

Pneu–P–23—Pneumococcal Polysaccharide–23-valent

8961 single dose ..................................................................................................................................... 8.85

Rab—Rabies–post–exposure

8751 single dose ..................................................................................................................................... 8.85

Rab—Rabies Vaccine–pre–exposure

8761 single dose ..................................................................................................................................... 8.85

Td—Tetanus, Diphtheria–adult

8651 single dose ..................................................................................................................................... 8.85

TdaP—Tetanus, Diphtheria, accellular Pertussis–adult

8907 single dose ..................................................................................................................................... 8.85

Td–IPV—Tetanus, Diphtheria, Inactivated Polio Virus–adult

8805 single dose ..................................................................................................................................... 8.85

Var—Varicella

8674 single dose ..................................................................................................................................... 8.85

PASSIVE IMMUNIZING AGENTS

BAtx—Botulism Antitoxin type A, B, E

8910 single dose ..................................................................................................................................... 8.85

DAtx—Diphtheria Antitoxin

8928 single dose ..................................................................................................................................... 8.85

HBIg—Hepatitis B Immunoglobulin

8916 single dose ..................................................................................................................................... 8.85

Ig—Immune globulin (human)

8920 single dose ..................................................................................................................................... 8.85

RabIg—Rabies Immunoglobulin

8768 single dose ..................................................................................................................................... 8.85

TIg—Tetanus Immunoglobulin

8690 single dose ..................................................................................................................................... 8.85

Digestive System

J-6 April 1, 2010

UNIT VALUE

3631 Inguinal hernia, initial ............................................................................................................... 338.75 20.000

3632 pediatric with negative contralateral exploration ................................................................... 340.70 20.000

3636 with excision of hydrocele and/or orchiectomy ..................................................................... 402.90 20.000

3635 recurrent ................................................................................................................................. 423.30 21.375

3633 Incarcerated hernia without bowel resection ............................................................................. 418.20 21.375

3734 Wound disruption (postop), secondary suture ........................................................................... 368.85 22.750

3591 Peritoneo-venous shunt, placement ........................................................................................... 421.60 21.375

3592 removal for infection.............................................................................................................. 238.05 21.375

3593 removal and replacement of valve for blockage .................................................................... 177.50 21.375

3707 Diaphragm (transabdominal or thoracic), rupture, early repair ................................................. 691.75 24.125

3708 diaphragm hernias excluding anti-reflux surgery ................................................................... 700.40 25.500

3706 with prosthesis, add ................................................................................................................ 250.00

RESECTION

3595 Abdominal lipectomy—small (vertical skin resection up to 15 cm.) ........................................ 608.15 21.375

3596 Abdominal lipectomy—large (vertical skin resection 15 cm. to 30 cm.) .................................. 608.15 21.375

3597 Abdominal lipectomy—massive (vertical skin resection over 30 cm.) ..................................... 979.20 21.375

Note: These procedures have certain restrictions under the Regulations when

done as elective surgery. Written prior approval from the Minister is a

condition for the payment of claims.

3580 Retroperitoneal or transperitoneal tumor or cyst; excision ........................................................ 817.15 22.750

3619 Unlisted or Unusually Complicated .................................................................................. By Report 22.750

ENDOSCOPY

Note: Tariffs 3000, 3002, 3004, 3006, 3008 and 3010 may only be claimed in

addition to gastrointestinal endosopic procedure tariffs.

3000* Balloon dilatation of colonic, pyloric, esophageal or small bowel strictures, add ....................... 83.40 21.375

3002* Botox injection, add..................................................................................................................... 48.50 21.375

3004* Hemostasis G. I. Tract by any endoscopic method or technique (e.g., cautery,

injection, banding), add ............................................................................................................. 110.35 21.375

3006* Hemodynamic instability, add ..................................................................................................... 51.00 24.125

Note: Claim, for Tariff 3006, must indicate that the patient exhibits one (1) or

more of the following: Pulse Rate >100/minute; Blood pressure <80

systolic; hemoglobin <80; On-going bleeding.

3008* Placement of jejunal or small bowel feeding tube beyond pyloris, add....................................... 50.00 20.000

3010 Insertion of small bowel or colonic stent (s) (includes dilatation if necessary), add ................. 137.00 21.375

Note: Tariff 3000 may not be claimed in addition to Tariff 3010.

Digestive System

April 1, 2010 J-7

0005 Endoscopic Tray Fee .................................................................................................................. 100.00

May only be claimed in addition to Tariffs 3055, 3060, 3065 , 3095, 3121, 3122, 3123,

3185, 3186, 3187 and 3189 when the service is rendered in the physician’s office.

Note: Tray Fee tariff 0005 is claimable only in instances where expenses are

directly incurred by the physician for medical/surgical supplies. Tray Fee

tariff 0005 is not claimable in relation to services performed at a hospital,

personal care home or other publically funded facility or a facility on

contract with a Regional Health Authority to perform such insured services.

ESOPHAGUS

UNIT VALUE

3055* Esophagoscopy, diagnostic, with or without biopsy .................................................................. 102.00 21.375

3063* subsequent, same hospital admission ........................................................................................68.00 21.375

3060* with bronchoscopy ....................................................................................................................99.85 22.750

3057 with foreign body removal...................................................................................................... 175.95 21.375

3065* with injection of varices or band ligation ............................................................................... 191.40 21.375

STOMACH

3121* Gastroscopy, diagnostic with or without biopsy ........................................................................ 110.95 21.375

3122* with polypectomy ................................................................................................................... 180.65 21.375

3123* Esophagogastroduodenoscopy (EGD) with or without biopsy .................................................. 114.55 21.375

SMALL INTESTINE

3190* Small bowel enteroscopy by mouth using designated enteroscope or colonoscope ................... 204.00 21.375

Note: Pathology report may be required.

3192 Capsule Endoscopy–Includes the review of imaging of the small bowel and report to

the referring physician ................................................................................................................ 412.10

Note: 1) A visit cannot be claimed at the same sitting as the initiation of capsule

endoscopy.

2) Minimum time for the service is one (1) hour including the assessment

of referrals to determine indication for procedure.

3) Patients will have previously undergone some or all of the following:

Esophagogastroduodenoscopy (EGD), colonoscopy, small bowel

enteroscopy and/or small bowel series–radiography & fluoroscopy.

4) Payable only for services provided by a Gastroenterologist at a facility

to be designated by Manitoba Health (Health Science Centre and

Brandon Regional Health Centre).

Audio-Vestibular System

April 1, 2010 S-1

S

AUDIO-VESTIBULAR SYSTEM

These benefits cannot be correctly interpreted without reference to the Rules of Application.

DIAGNOSTIC PROCEDURES

Automated impedance tympanometer with hand-held micro tympanometer

(included in visit fee) ...................................................................................................................... F/S

Audiogram—screening ................................................................................................................... F/S

9745* Audiogram—puretone—air & bone (bilateral), total ...................................................................20.40

9740* professional portion ................................................................................................................8.55

9746* air & bone with speech tests (bilateral), total ...........................................................................26.50

9742* professional portion ..............................................................................................................11.40

9749* air & bone with speech tests and suprathreshold tests (bilateral), total ....................................24.00

9744* professional portion ..............................................................................................................13.90

9770* Automated impedance tympanometer with or without ipsilateral or contralateral

reflexes, total ................................................................................................................................10.20

9786* professional portion ....................................................................................................................7.10

~9752 Vestibular Evoked Myogenic Potential Test, professional fee for interpretation .........................50.00

Note: 1) Tariff ~9752 is payable only for tests provided in a facility designated

by Manitoba Health.

2) Tariff ~9752 may only be claimed by physicians designated as

specialists in Otolaryngology by the College of Physicians and

Surgeons of Manitoba.

ADVANCED TESTING

Note: 1) A maximum of three (3) advanced tests are payable at the same sitting.

2) When performed at the same sitting as Tariffs 9770 and 9786, a

maximum of two (2) advanced tests are payable in addition.

3) When performing contralateral reflexes as a single test, claim

Tariff 9770 or 9786.

4) The benefit amounts listed are for unilateral or bilateral testing.

5) These tariffs are payable only to physicians with appropriate training

in advanced testing as determined by The College of Physicians and

Surgeons.

9788* Four (4) frequency acoustic reflex thresholds to test the integrity across brain stem

pathways, total .............................................................................................................................15.00

9797* professional portion ....................................................................................................................6.35

9709* to assist in diagnosis of recruitment, total .................................................................................15.00

9712* professional portion ................................................................................................................6.35