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  1. NUCLEAR MEDICINE – IN VIVO PREAMBLE SPECIFIC ELEMENTS For Facility Fee Component (F fee) A. Preparing the patient for the procedure. B. Performing the diagnostic procedure(s). C. Making arrangements for any appropriate follow-up care. D. Providing records of the results of the procedure to the interpreting physician. E. Discussion with, and providing information and advice to, the patient or patient’s representative, whether by telephone or otherwise, on matters related to the service. F. Preparing and transmitting a written, signed and dated interpretive report of the procedure to the referring physician. G. Providing premises, equipment, supplies and personnel for all specific elements of the facility fee components. LE OTHER TERMS AND DEFINITIONS 1. Professional and facility fee components are claimed separately. Claims for the facility fee component F are submitted using listed fee code with suffix B. Where the IHF is submitting professional fee claims on behalf of the interpreting physician, claims for professional component are submitted using fee code with suffix C (e.g. J802C). 2. If examination of Brain, Lung, Liver or Spleen is limited to one view, the benefit (F fee) is to be reduced by 50%. 3. Repeat studies on the same day may be claimed only after exercise or drug intervention. Schedule of Facility Fees for Independent Health Facilities Revised: October 1, 2015 2

  2. NUCLEAR MEDICINE – IN VIVO Code CARDIOVASCULAR SYSTEM Venography J802 - peripheral and superior vena cava First Transit J804 - without blood pool images J867 - with blood pool images Cardioangiography J806 - first pass for shunt detection, cardiac output and transit studies Myocardial Perfusion Scintigraphy J807 - resting, immediate post stress J866 - application of SPECT (maximum one per examination) add J808 - delayed J809 - application of SPECT (maximum two per examination) add Myocardial scintigraphy J810 - acute infarction, injury Myocardial wall motion J811 - studies J812 - repeat same day (to a maximum of three repeats) J813 - studies with ejection fraction J814 - repeat same day (to a maximum of three repeats) Note: J811 and/or J812 rendered in conjunction with J813 and/or J814 are insured services payable at nil. J815 Detection of venous thrombosis using radioiodinated fibrinogen up to ten days ENDOCRINE SYSTEM Adrenal scintigraphy J816 - with iodocholesterol J868 - with iodocholesterol and dexamethasone suppression J869 - with MIBG Thyroid scintigraphy J818 - with Tc99m or I-131 J871 - with I-123 Thyroid J817 - uptake J870 - repeat F 96.35 16.10 57.30 95.10 217.55 43.50 80.10 43.50 88.25 95.10 48.15 135.15 48.15 131.70 385.90 451.30 555.35 64.15 103.10 28.65 14.65 Schedule of Facility Fees for Independent Health Facilities Revised: October 1, 2015 3

  3. NUCLEAR MEDICINE – IN VIVO Code ENDOCRINE SYSTEM (continued) Parathyroid scintigraphy J820 -dual isotope technique with T1201 and Tc99m Iodine J872 Metastatic survey with I-131 GASTROINTESTINAL SYSTEM Schilling test J821 - single isotope J823 - dual isotope Malabsorption test J824 - with C14 substrate J873 - with whole body counting Gastrointestinal J825 - protein loss J874 - blood loss using – Cr51 J829 - transit Calcium absorption J826 - Ca45 J875 - Calcium47 absorption/excretion J827 Oesophageal motility studies – one or more Gastro-oesophageal J876 - reflux J877 - aspiration Abdominal scintigraphy – for gastrointestinal bleed J830 - Tc99m sulphur colloid or Tc04 J878 - labelled RBCs J879 - LeVeen shunt patency J831 Biliary scintigraphy J832 Liver/spleen scintigraphy J833 Salivary gland scintigraphy GENITOURINARY SYSTEM J834 Dynamic renal imaging Computer assessed renal function J835 - includes first transit J880 - repeat after pharmacological intervention F 234.70 240.60 44.65 48.15 57.30 137.70 82.45 61.90 103.10 61.90 253.10 118.90 56.70 40.15 87.00 143.20 66.30 114.50 80.10 96.25 96.25 131.70 44.85 Schedule of Facility Fees for Independent Health Facilities Revised: October 1, 2015 4

  4. NUCLEAR MEDICINE – IN VIVO Code GENITOURINARY SYSTEM (continued) J836 Static renal scintigraphy J837 ERPF by blood sample method J838 GFR by blood sample method J839 Cystography for vesicoureteric reflux Testicular and scrotal scintigraphy J840 - includes first transit HAEMATOPOIETIC SYSTEM J841 Plasma volume J843 Red cell volume J847 Ferrokinetics – clearance, turnover, and utilization J848 Red cell, white cell or platelet survival J849 Red cell survival with serial surface counts Bone marrow scintigraphy J881 - whole body J882 - single site In-111 leukocyte scintigraphy J883 - whole body J884 - single site MUSCULOSKELETAL SYSTEM Bone scintigraphy J850 - general survey J851 - single site Gallium scintigraphy J852 - general survey J853 - single survey Application of Tomography (SPECT) J819 - where each SPECT image represents a different organ or body area, to J852, maximum three images per examination add Note: J850 and J851 are not to be billed together. J804 may be claimed in addition to J850 or J851 for blood pool study. NERVOUS SYSTEM CSF circulation J857 - with Tc99m or I-131 HAS J885 - with In-111 F 33.25 40.15 40.15 120.55 82.45 43.50 48.15 400.95 102.60 148.25 113.70 84.85 364.30 320.80 103.70 84.85 177.55 123.70 43.50 120.25 308.20 Schedule of Facility Fees for Independent Health Facilities Revised: October 1, 2015 5

  5. NUCLEAR MEDICINE – IN VIVO Code NERVOUS SYSTEM (continued) J886 - via shunt puncture J858 Brain scintigraphy RESPIRATORY SYSTEM J859 Perfusion lung scintigraphy J887 Ventilation lung scintigraphy J860 Perfusion and ventilation scintigraphy – same day MISCELLANEOUS J861 Radionuclide lymphangiogram J862 Ocular tumour localization J864 Tear duct scintigraphy J865 Total body counting Application of Tomography (SPECT), other than to J808 or J852 J866 - maximum one per Nuclear Medicine examination add SCINTIMAMMOGRAPHY Scintimammography is not eligible for payment unless at least one of the following conditions is met: a. the patient has a dense breast(s) and one or both of the following risk factors: i. a first degree relative with breast cancer diagnosed prior to age 50; or ii. a first degree relative with breast cancer diagnosed over age 50 and patient is within 5 years of the age when the relative was diagnosed with breast cancer. b. architectural distortion of the breasts due to prior breast surgery, radiotherapy, chemotherapy or the presence of breast prosthesis rendering mammography interpretation difficult; c. malignant breast lesion when mammography is unable to exclude multifocal disease; or d. solitary lesion identified on mammography of greater than 1 cm Scintimammography J863 - unilateral or bilateral Note: For the purpose of this provision, “dense breast(s)” means (a) breast(s) occupied by over 75% fibroglandular tissue as noted on mammography. F 88.55 90.40 85.90 107.70 171.85 112.20 75.60 97.35 187.95 43.50 99.95 Schedule of Facility Fees for Independent Health Facilities Revised: October 1, 2015 6