J476

PDF page 402 / G6

DIAGNOSTIC ULTRASOUND
PELVIS
                                                                                                   H             P
   Pelvis
 J162 - complete* ...........................................................................     48.75         26.55
 J138 Intracavitary ultrasound* (e.g. transrectal, transvaginal) ........            48.75 26.50
     Note:
     *For ovulation induction purposes, the limit is one per cycle. Additional ultrasounds may be
     claimed as J164.
 J165 Transvaginal sonohysterography - may include saline or other
          intracavitary contrast media except Echovist for
          demonstration of tubal patency ..........................................  99.95 33.15
 J476 Transvaginal sonohysterography - including Echovist contrast
          media for demonstration of tubal patency ..........................       232.90 30.65
     Note:
     J138 and J161 rendered in conjunction with J165 are insured services payable at nil.
       [Commentary:
       See Diagnostic and Therapeutic Procedures section page J46 for Transvaginal
       sonohysterography, introduction of catheter with or without injection or contrast media (G399).]
 J163       - limited study - for other than pregnancy .............................              32.10         17.55
   Intracavitary ultrasound
 J161 - limited - for other than pregnancy....................................... 32.10 16.25
     Note:
     1.For residual urine measurement by ultrasound (G900), see Diagnostic and Therapeutic
       Procedures, section J, Urology.
     2.Residual urine measurement by ultrasound (G900) is not eligible for payment when rendered
       with an ultrasound of the pelvis or intracavitary ultrasound.
 J164 Follicle monitoring studies ......................................................          24.40         12.30
       [Commentary:
       Ultrasound services are not insured when rendered to support in-vitro fertilization services or
       artificial insemination services. See Regulation 552 section 24(1) paragraph 23 and 29 under
       the Act.]

PDF page 460 / J46

+ G362 Insertion of laminaria tent .......................................................                  6.25
  E870    - when laminaria tent supplied by the physician........... add                                    8.35
  G334 Telephone supervisory fee for ovulation induction with human
          menopausal gonadotropins or gonadotropin-releasing
          hormone (not eligible for payment same day as visit), to a
          maximum of 10 per cycle ........................................per call                          4.05
  G399 Transvaginal sonohysterography, introduction of catheter, with
          or without injection of contrast media .................................                        44.15
        Note:
        G399 is only eligible for payment when transvaginal sonohysterography professional and
        technical services (J165 or J476) are rendered (either by the same or another physician).
        [Commentary:
        1.See Diagnostic Ultrasound section page G6.
        2.G334 is not insured when rendered to support in-vitro fertilization services or artificial
          insemination services. See Regulation 552 section 24(1) paragraph 23 and 29 under the
          Act.]
    Cervical cancer screening
+ G365 Collection of cervical cancer screening specimen(s)..............                                  12.00
  E430    - when cervical cancer screening specimen(s) are collected
            outside of hospital or ICHSC, to G365....................... add                               11.95

Master, record 2655. Record Layout PDF, page 1.

J47620260401999999990000000000000002705000000000000000000030650000000306500

Auxiliary master fields are preserved as raw scaled values. The linked layout calls them zero-filled, but this edition contains non-zero values. They are not presented as final dollar fees or PDF units.