SOMB; Medical Price List - January 1, 2017

ALBERTA HEALTH CARE INSURANCE PLAN

d Medical

Price List

e As Of Supersed 01 January 2017

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I. CERTAIN DIAGNOSTIC AND THERAPEUTIC PROCEDURES . . . . . . . . . . . . . . . . . 1 01 NONOPERATIVE ENDOSCOPY . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 01.0 Nonoperative endoscopy of respiratory tract . . . . . . . . . . . . . . . 1 01.1 Nonoperative endoscopy of upper gastrointestinal tract . . . . . . . . . 2 01.2 Nonoperative endoscopy of lower gastrointestinal tract . . . . . . . . . 3 01.3 Other nonoperative endoscopy . . . . . . . . . . . . . . . . . . . . . . 5 02 DIAGNOSTIC RADIOLOGY AND RELATED TECHNIQUES . . . . . . . . . . . . . . . . . 5 Radiology Section - Please See Section X 02.7 Other x-ray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 02.8 Diagnostic ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . 6

d 03 CLINICAL EVALUTION AND EXAMINATION . . . . . . . . . . . . . . . . . . . . . . 7

03.0 Diagnostic interview and evaluation or consultation . . . . . . . . . . . 7

e 03 CLINICAL EVALUATION AND EXAMINATION . . . . . . . . . . . . . . . . . . . . . 7 03.0 Diagnostic interview and evaluation or consultation . . . . . . . . . . . 7 d 03.1 Measurements and manual examinations of nervous system and sense organs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 03.2 Measurements and manual examinations of genitourinary system . . . . . 24 e 03.3 Other measurements and manual examinations Refer to GRs 11.2.1 and 11.2.2 for additional information pertaining to HSCs 03.37A to 03.38X inclusive. . . . . . . . . . . . . . . . . . . 25 s 03.4 Cardiac stress tests and pacemaker checks . . . . . . . . . . . . . . . 26 r 03.5 Other cardiac function tests . . . . . . . . . . . . . . . . . . . . . 26 03.6 Other cardiovascular measurements . . . . . . . . . . . . . . . . . . . 27 e 03.7 General physical examination . . . . . . . . . . . . . . . . . . . . . . 27 06 NUCLEAR MEDICINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

p 06.3 Other therapeutic radiology and nuclear medicine . . . . . . . . . . . 27

07 PHYSICAL MEDICINE, REHABILITATION, AND RELATED PROCEDURES . . . . . . . . . 28 07.0 Diagnostic physical medicine . . . . . . . . . . . . . . . . . . . . . 28

u 07.2 Other physical medicine - musculoskeletal manipulation . . . . . . . . 28 S07.4 Skeletal traction and other traction . . . . . . . . . . . . . . . . . 29

07.5 Other immobilization, pressure, and attention to wound . . . . . . . . 29 08 DIAGNOSTIC AND THERAPEUTIC PSYCHOLOGY AND PSYCHIATRY . . . . . . . . . . . 31

08.1 Psychiatric evaluations, interviews, and consultations . . . . . . . . 31 08.3 Psychiatric drug and shock therapy . . . . . . . . . . . . . . . . . . 33

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08.4 Other psychiatric therapeutic procedures . . . . . . . . . . . . . . . 34

09 OPHTHALMOLOGICAL AND OTOLOGICAL DIAGNOSIS AND TREATMENT . . . . . . . . . . 35

09.0 General and subjective eye examination . . . . . . . . . . . . . . . . 35

09.1 Examinations of form and structure of eye . . . . . . . . . . . . . . . 35

09.2 Objective functional tests of eye . . . . . . . . . . . . . . . . . . . 36

09.4 Nonoperative procedures related to hearing . . . . . . . . . . . . . . 36

10 NONOPERATIVE INTUBATION, IRRIGATION, AND MANIPULATION PROCEDURES . . . . . 36

10.0 Nonoperative intubation of respiratory and gastrointestinal tracts . . 36

10.2 Other nonoperative dilation and manipulation procedures . . . . . . . . 37

10.3 Nonoperative alimentary tract irrigation, cleaning and local instillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

d 10.5 Nonoperative irrigation, cleaning, and local instillation of genitourinary system . . . . . . . . . . . . . . . . . . . . . . . . 38

e 11 REPLACEMENT AND REMOVAL OF THERAPEUTIC APPLIANCES . . . . . . . . . . . . . 39 11.0 Nonoperative replacement of gastrointestinal appliances . . . . . . . . 39

11.2 Other nonoperative replacement . . . . . . . . . . . . . . . . . . . . 39

d 11.7 Nonoperative removal of therapeutic device from genital system . . . . 39

11.8 Other nonoperative removal of therapeutic device . . . . . . . . . . . 40

e 12 NONOPERATIVE REMOVAL OF FOREIGN BODY . . . . . . . . . . . . . . . . . . . 40

12.0 Removal of (non-penetrating) intraluminal foreign body from

s respiratory tract without incision . . . . . . . . . . . . . . . . . . 40

12.1 Removal of (non-penetrating) intraluminal foreign body from

r digestive system without incision . . . . . . . . . . . . . . . . . . . 41

12.2 Removal of (non-penetrating) intraluminal foreign body from other sites without incision . . . . . . . . . . . . . . . . . . . . . . . . 41

e 12.3 Removal of other foreign body from head and neck without incision . . . 42

13 OTHER NONOPERATIVE PROCEDURES . . . . . . . . . . . . . . . . . . . . . . . 42

p 13.4 Injection or infusion of other therapeutic or prophylactic substance . 42

13.5 Other injection or infusion of other therapeutic or prophylactic substance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

u 13.6 Respiratory therapy . . . . . . . . . . . . . . . . . . . . . . . . . . 44 S13.7 Conversion of cardiac rhythm . . . . . . . . . . . . . . . . . . . . . 44

13.8 Miscellaneous physical procedures . . . . . . . . . . . . . . . . . . . 45

13.9 Other miscellaneous diagnostic and therapeutic procedures . . . . . . . 45

II. OPERATIONS ON THE NERVOUS SYSTEM . . . . . . . . . . . . . . . . . . . . . . 48

14 INCISION AND EXCISION OF SKULL, BRAIN AND CEREBRAL MENINGES

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Intracranial procedure involving microsurgical technique,for a second neurosurgeon, refer to Price List . . . . . . . . . . . . . . . . . . . . 48

14.0 Cranial puncture . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

14.1 Craniotomy and craniectomy . . . . . . . . . . . . . . . . . . . . . . 48

14.2 Incision of brain and cerebral meninges . . . . . . . . . . . . . . . . 52

14.3 Operations on thalamus and globus pallidus (including ansa and cingulus) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

14.4 Other excision or destruction of brain and meninges . . . . . . . . . . 55

14.8 Invasive diagnostic procedures on skull, brain, and cerebral meninges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

15 OTHER OPERATIONS ON SKULL, BRAIN, AND CEREBRAL MENINGES . . . . . . . . . . 60

15.0 Cranioplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

d 15.1 Repair of cerebral meninges . . . . . . . . . . . . . . . . . . . . . . 63

15.2 Ventriculostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

e 15.3 Extracranial ventricular shunt . . . . . . . . . . . . . . . . . . . . 64

15.4 Revision of ventricular shunt . . . . . . . . . . . . . . . . . . . . . 65

d 15.9 Other operations on skull, brain, and cerebral meninges . . . . . . . . 65

16 OPERATIONS ON SPINAL CORD AND SPINAL CANAL STRUCTURES . . . . . . . . . . . 66

e NOTE: The listed benefits are payable irrespective of the number of vertebrae involved if one incision utilized, unless otherwise stated. 16.0 Exploration and decompression of spinal canal . . . . . . . . . . . . . 66

s 16.1 Division of intraspinal nerve root . . . . . . . . . . . . . . . . . . 69 r 16.2 Chordotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

16.3 Excision or destruction of lesion of spinal cord and spinal meninges . 71

e 16.4 Plastic operations on spinal cord and spinal meninges . . . . . . . . . 73

16.5 Freeing of adhesions of spinal cord and nerve roots . . . . . . . . . . 76

p 16.8 Invasive diagnostic procedures on spinal cord and spinal canal structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

16.9 Other operations on spinal cord and canal structures . . . . . . . . . 78

u 17 OPERATIONS ON CRANIAL AND PERIPHERAL NERVES . . . . . . . . . . . . . . . . 79 S17.0 Incision, division, and excision of cranial and peripheral nerves . . . 79

17.1 Destruction of cranial and peripheral nerves . . . . . . . . . . . . . 84

17.2 Suture of cranial and peripheral nerves . . . . . . . . . . . . . . . . 84

17.3 Freeing of adhesions and decompression of cranial and peripheral nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

17.4 Cranial or peripheral nerve graft . . . . . . . . . . . . . . . . . . . 89

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17.5 Transposition of cranial and peripheral nerves . . . . . . . . . . . . 90 17.6 Other cranial or peripheral neuroplasty . . . . . . . . . . . . . . . . 91 17.7 Injection into peripheral nerve . . . . . . . . . . . . . . . . . . . . 92 17.8 Invasive diagnostic procedures on peripheral nervous system . . . . . . 92 17.9 Other operations on cranial and peripheral nerves . . . . . . . . . . . 93 18 OPERATIONS ON SYMPATHETIC NERVES OR GANGLIA . . . . . . . . . . . . . . . . 94 18.1 Sympathectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 18.2 Injection into sympathetic nerve or ganglion . . . . . . . . . . . . . 95 III. OPERATIONS ON THE ENDOCRINE SYSTEM . . . . . . . . . . . . . . . . . . . . 96 19 OPERATIONS ON THYROID AND PARATHYROID GLANDS . . . . . . . . . . . . . . . 96

d 19.0 Incision of thyroid field . . . . . . . . . . . . . . . . . . . . . . . 96

19.1 Unilateral thyroid lobectomy . . . . . . . . . . . . . . . . . . . . . 96

e 19.3 Complete thyroidectomy . . . . . . . . . . . . . . . . . . . . . . . . 97

19.6 Excision of thyroglossal duct or tract . . . . . . . . . . . . . . . . 97 19.7 Parathyroidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

d 19.8 Invasive diagnostic procedures on thyroid and parathyroid glands . . . 99

20 OPERATIONS ON OTHER ENDOCRINE GLANDS . . . . . . . . . . . . . . . . . . . 99

e 20.1 Partial adrenalectomy . . . . . . . . . . . . . . . . . . . . . . . . . 99

20.5 Hypophysectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100

s 20.7 Thymectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 r IV. OPERATIONS ON THE EYES . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

21 OPERATIONS ON LACRIMAL APPARATUS . . . . . . . . . . . . . . . . . . . . . 102

e 21.3 Manipulation of lacrimal passage (tract) . . . . . . . . . . . . . . . 102

21.4 Incision of lacrimal sac and passage . . . . . . . . . . . . . . . . . 103

p 21.6 Repair of canaliculus and punctum . . . . . . . . . . . . . . . . . . . 104

21.7 Fistulization of lacrimal tract to nasal cavity . . . . . . . . . . . . 105 22 OPERATIONS ON EYELIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

u 22.1 Excision of lesion or tissue of eyelid . . . . . . . . . . . . . . . . 105 S22.3 Correction of entropion or ectropion . . . . . . . . . . . . . . . . . 106

22.4 Correction of blepharoptosis . . . . . . . . . . . . . . . . . . . . . 107 22.5 Blepharorrhaphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 22.6 Other repair of eyelid . . . . . . . . . . . . . . . . . . . . . . . . 109 22.7 Epilation of eyelid . . . . . . . . . . . . . . . . . . . . . . . . . . 109

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22.8 Invasive diagnostic procedures on eyelid . . . . . . . . . . . . . . . 109 23 OPERATIONS ON OCULAR MUSCLES OR TENDONS . . . . . . . . . . . . . . . . . . 110

23.9 Other operations on ocular muscles or tendons . . . . . . . . . . . . . 110 24 OPERATIONS ON CONJUNCTIVA . . . . . . . . . . . . . . . . . . . . . . . . . 110

24.1 Other incision of conjunctiva . . . . . . . . . . . . . . . . . . . . . 110 24.2 Excision or destruction of lesion or tissue of conjunctiva . . . . . . 111 24.3 Conjunctivoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 24.5 Suture of conjunctiva . . . . . . . . . . . . . . . . . . . . . . . . . 112 24.9 Other operations on conjunctiva . . . . . . . . . . . . . . . . . . . . 112 25 OPERATIONS ON CORNEA . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

d 25.1 Incision of cornea . . . . . . . . . . . . . . . . . . . . . . . . . . 112

25.2 Excision of pterygium . . . . . . . . . . . . . . . . . . . . . . . . . 113

e 25.3 Excision or destruction of other lesion or tissue of cornea . . . . . . 113

IV. OPERATIONS ON THE EYES . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 25 OPERATIONS ON CORNEA . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

d 25.4 Suture of cornea . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

25.5 Corneal transplant . . . . . . . . . . . . . . . . . . . . . . . . . . 115

e 25.6 Other repair of cornea . . . . . . . . . . . . . . . . . . . . . . . . 117

25.8 Invasive diagnostic procedures on cornea . . . . . . . . . . . . . . . 117

s 26 OPERATIONS ON IRIS, CILIARY BODY, SCLERA, AND ANTERIOR CHAMBER . . . . . . 118 r 26.2 Operations for the relief of intraocular tension . . . . . . . . . . . 118

26.3 Facilitation of intraocular circulation . . . . . . . . . . . . . . . . 119

e 26.4 Excision or destruction of lesion of iris, ciliary body, and sclera . . 119

26.5 Other iridectomy or iridotomy . . . . . . . . . . . . . . . . . . . . . 119

p 26.6 Iridoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

26.7 Scleroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 26.9 Other operations on iris, ciliary body, sclera, and anterior chamber . 122

u 27 OPERATIONS ON LENS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 S27.3 Discission of lens and capsulotomy . . . . . . . . . . . . . . . . . . 123

27.4 Intracapsular extraction of lens . . . . . . . . . . . . . . . . . . . 123 27.5 Extracapsular extraction of lens . . . . . . . . . . . . . . . . . . . 124 27.7 Insertion of prosthetic lens . . . . . . . . . . . . . . . . . . . . . 124 27.9 Other operations on lens . . . . . . . . . . . . . . . . . . . . . . . 125

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28 OPERATIONS ON RETINA, CHOROID, AND VITREOUS . . . . . . . . . . . . . . . . 126 28.2 Scleral buckling with implant . . . . . . . . . . . . . . . . . . . . . 126 28.4 Other operations for repair of retina . . . . . . . . . . . . . . . . . 127 28.5 Excision or destruction of lesion of retina or choroid . . . . . . . . 127 28.7 Operations on vitreous . . . . . . . . . . . . . . . . . . . . . . . . 128 28.8 Invasive diagnostic procedures on retina, choroid, and vitreous . . . . 131

29 OPERATIONS ON ORBIT AND EYEBALL . . . . . . . . . . . . . . . . . . . . . . 131 29.0 Orbitotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 29.2 Evisceration of eyeball . . . . . . . . . . . . . . . . . . . . . . . . 133 29.3 Removal of eyeball . . . . . . . . . . . . . . . . . . . . . . . . . . 133

d 29.4 Exenteration of orbital contents . . . . . . . . . . . . . . . . . . . 134

29.5 Insertion of ocular or orbital implant . . . . . . . . . . . . . . . . 134

e 29.9 Other operations on orbit or eyeball . . . . . . . . . . . . . . . . . 134

V. OPERATIONS ON THE EARS . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 30 OPERATIONS ON EXTERNAL EAR . . . . . . . . . . . . . . . . . . . . . . . . 135

d 30.1 Excision or destruction of lesion of external ear . . . . . . . . . . . 135

30.3 Suture of (traumatic) laceration of external ear . . . . . . . . . . . 136

e 30.4 Surgical correction of prominent ear . . . . . . . . . . . . . . . . . 137

30.6 Other plastic repair of external ear . . . . . . . . . . . . . . . . . 137

s 30.8 Invasive diagnostic procedures on external ear . . . . . . . . . . . . 138 r 30.9 Other operations on external ear . . . . . . . . . . . . . . . . . . . 138

31 RECONSTRUCTIVE OPERATIONS ON MIDDLE EAR . . . . . . . . . . . . . . . . . . 138

e 31.0 Stapes mobilization . . . . . . . . . . . . . . . . . . . . . . . . . . 138

31.1 Stapedectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

p 31.3 Other operations on ossicular chain . . . . . . . . . . . . . . . . . . 139

31.4 Myringoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 31.5 Other tympanoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . 140

u 31.9 Other repair of middle ear . . . . . . . . . . . . . . . . . . . . . . 141 S32 OTHER OPERATIONS ON MIDDLE AND INNER EAR . . . . . . . . . . . . . . . . . 141

32.0 Myringotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 32.1 Removal of tympanostomy tube . . . . . . . . . . . . . . . . . . . . . 141 32.2 Incision of mastoid and middle ear . . . . . . . . . . . . . . . . . . 142 32.3 Mastoidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142

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32.5 Fenestration of inner ear . . . . . . . . . . . . . . . . . . . . . . . 144 32.7 Incision, excision, and destruction of inner ear . . . . . . . . . . . 144 32.8 Invasive diagnostic procedures on middle and inner ear . . . . . . . . 146 32.9 Other operations on middle and inner ear and eustachian tube . . . . . 146 VI. OPERATIONS ON THE NOSE, MOUTH,AND PHARYNX . . . . . . . . . . . . . . . . . 147 33 OPERATIONS ON NOSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 33.0 Control of epistaxis . . . . . . . . . . . . . . . . . . . . . . . . . 147 33.1 Incision of nose . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 33.2 Excision or destruction of lesion of nose . . . . . . . . . . . . . . . 148 33.3 Resection of nose . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

d 33.5 Turbinectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150

33.6 Reduction of nasal fracture . . . . . . . . . . . . . . . . . . . . . . 150

e 33.7 Repair and plastic operations on the nose . . . . . . . . . . . . . . . 151

33.9 Other operations on nose . . . . . . . . . . . . . . . . . . . . . . . 154 34 OPERATIONS ON NASAL SINUSES . . . . . . . . . . . . . . . . . . . . . . . . 154

d 34.0 Puncture of nasal sinus . . . . . . . . . . . . . . . . . . . . . . . . 154

34.1 Intranasal antrotomy . . . . . . . . . . . . . . . . . . . . . . . . . 155

e 34.2 External maxillary antrotomy . . . . . . . . . . . . . . . . . . . . . 155

34.3 Frontal sinusotomy and sinusectomy . . . . . . . . . . . . . . . . . . 156

s 34.5 Other nasal sinusectomy . . . . . . . . . . . . . . . . . . . . . . . . 158 r 34.8 Invasive diagnostic procedures on nasal sinus . . . . . . . . . . . . . 160

35 REMOVAL AND RESTORATION OF TEETH . . . . . . . . . . . . . . . . . . . . . 160

e 35.0 Forceps extraction of tooth (multiple) (single) . . . . . . . . . . . . 160

36 OTHER OPERATIONS ON TEETH, GUMS AND ALVEOLI . . . . . . . . . . . . . . . . 161

p 36.9 Other dental operations . . . . . . . . . . . . . . . . . . . . . . . . 161

37 OPERATIONS ON TONGUE . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 37.1 Partial glossectomy . . . . . . . . . . . . . . . . . . . . . . . . . . 161

u 37.2 Complete glossectomy . . . . . . . . . . . . . . . . . . . . . . . . . 162 S37.8 Invasive diagnostic procedures on tongue . . . . . . . . . . . . . . . 162

37.9 Other operations on tongue . . . . . . . . . . . . . . . . . . . . . . 163 38 OPERATIONS ON SALIVARY GLANDS AND DUCTS . . . . . . . . . . . . . . . . . . 164

38.0 Incision of salivary gland or duct . . . . . . . . . . . . . . . . . . 164 38.2 Sialoadenectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164

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