Note 2016 CPT Mod Description EVALUATION & MANAGEMENT SERVICES

Transcription

1 FAC IND Note 2016 CPT Mod Description EVALUATION & MANAGEMENT SERVICES PAR FEE* NON PAR FEE** LC*** EHR LC**** Brief Exam - New patient Level I $40.55 $38.52 $44.30 $43.41 $43.41 $42.55 Facility Brief Exam - New patient Level I $25.57 $24.29 $27.93 $27.37 $27.37 $ Expanded Exam - New patient Level 2 $69.75 $66.26 $76.20 $74.67 $74.67 $73.17 Facility Expanded Exam - New patient Level 2 $48.52 $46.09 $53.00 $51.95 $51.95 $ Detailed Exam - New patient Level 3 $ $96.22 $ $ $ $ Facility Detailed Exam - New patient Level 3 $74.11 $70.40 $80.96 $79.34 $79.34 $ Moderately Complex Exam - New patient Level 4 $ $ $ $ $ $ Facility Moderately Complex Exam - New patient Level 4 $ $ $ $ $ $ Highly Complex Exam - New patient Level 5 $ $ $ $ $ $ Facility Highly Complex Exam - New patient Level 5 $ $ $ $ $ $ Nonphysician - Established patient Level 1 $18.30 $17.39 $20.00 $19.60 $19.60 $19.21 Facility Nonphysician - Established patient Level 1 $8.93 $8.48 $9.75 $9.56 $9.56 $ Brief Exam - Established patient Level 2 $40.25 $38.24 $43.98 $43.10 $43.10 $42.24 Facility Brief Exam - Established patient Level 2 $24.33 $23.11 $26.58 $26.05 $26.05 $ Expanded Exam - Established patient Level 3 $68.38 $64.96 $74.70 $73.21 $73.21 $71.75 Facility Expanded Exam - Established patient Level 3 $49.34 $46.87 $53.90 $52.82 $52.82 $ Moderately Complex Exam - Established patient Level 4 $ $96.02 $ $ $ $ Facility Moderately Complex Exam - Established patient Level 4 $75.78 $71.99 $82.79 $81.13 $81.13 $ Highly Complex Exam - Established patient Level 5 $ $ $ $ $ $ Facility Highly Complex Exam - Established patient Level 5 $ $ $ $ $ $ Facility Problem Focused/Straightforward - New or established Subsequent Nursing Facility Care Level 1 $42.77 $40.63 $46.72 $45.79 $45.79 $44.87 Facility Expanded/Low Complexity - New or established Subsequent Nursing Facility Care Level 2 $66.12 $62.81 $72.23 $70.78 $70.78 $69.37 Facility Detailed/Moderate Complex - New or established Subsequent Nursing Facility Care Level 3 $87.25 $82.89 $95.32 $93.41 $93.41 $91.55 Facility Comprehensive/High Complex - New or established Subsequent Nursing Facility Care Level 4 $ $ $ $ $ $ Facility Problem Focused/Straightforward - New patient Domiciliary, Rest Home or Custodial Care Services Level 1 $53.27 $50.61 $58.20 $57.04 $57.04 $55.90 Facility Expanded/Straightforward - New patient Domiciliary, Rest Homr or Custodial Care Services Level 2 $77.74 $73.85 $84.93 $83.23 $83.23 $81.56 Facility Detailed/Low Complexity - New patient Domiciliary, Rest Home or Custodial Care Services, Level 3 $ $ $ $ $ $ Facility Moderately Complex Exam - New patient Domiciliary, Rest Home or Custodial Care Services, Level 4 $ $ $ $ $ $ Facility Highly Complex Exam - New patient Domicilliary, Rest Home or Custodial Care Services, Level 5 $ $ $ $ $ $ Facility Problem Focused/Straightforward - Established patient Domicilliary, Rest Home or Custodial Care Services, Level 1 $57.91 $55.01 $63.26 $62.00 $62.00 $60.75 Facility Expanded/Straightforward - Established patient Domiciliary, Rest Home or Custodial Care Services, Level 2 $91.45 $86.88 $99.91 $97.91 $97.91 $95.96 Facility Moderately Complex Exam - Established patient Domicilliary, Rest Home or Custodial Care Services, Level 3 $ $ $ $ $ $ Facility Highly Complex Exam - Established patient Domicilliary, Rest Home or Custodial Care Services, Level 4 $ $ $ $ $ $ Facility Problem Focused/Straightforward - New patient Home Services, Level 1 $52.95 $50.30 $57.85 $56.68 $56.68 $55.55 Facility Expanded/Straightforward - New patient Home Services, Level 2 $76.49 $72.67 $83.57 $81.90 $81.90 $80.27 Facility Detailed/Low Complexity - New patient Home Services, Level 3 $ $ $ $ $ $ Facility Moderately Complex Exam - New patient Home Services, Level 4 $ $ $ $ $ $ Facility Highly Complex Exam - New patient Home Services, Level 5 $ $ $ $ $ $ Facility Problem Focused/Straightforward - Established patient Home Services, Level 1 $53.22 $50.56 $58.14 $56.98 $56.98 $55.84 Facility Expanded/Straightforward - Established patient Home Services, Level 2 $81.04 $76.99 $88.54 $86.77 $86.77 $85.03 Facility Moderately Complex Exam - Established patient Home Services, Level 3 $ $ $ $ $ $ Facility Highly Complex Exam - Established patient Home Services, Level 4 $ $ $ $ $ $ Prolonged Services HRS. $96.03 $91.23 $ $ $ $ Facility Prolonged Services HRS. $89.79 $85.30 $98.10 $96.13 $96.13 $ Prolonged Services - ADD.5 HRS. MORE $93.54 $88.86 $ $ $ $98.14 Facility Prolonged Services - ADD.5 HRS. MORE $87.30 $82.94 $95.38 $93.47 $93.47 $ Prolonged Services HRS. on-covered services Prolonged Services - ADD.5 HRS. MORE on-covered services New and/or Emerging Technology Services Reporting Codes 0198T Measurement of ocular blood flow by repetitive IOP sampling emerging technoogy 0207T Evacuation of meibomiam glands, automated, using heat and intermittent pressure, unilateral emerging technoogy 0289T Corneal incisions in the donor cornea created using a laser, in prep for penetrating or lamellar keratoplasty emerging technoogy 0290T Corneal incisions in the recipient cornea created using a laser, in prep for penetrating or lamellar keratoplasty emerging technoogy 0329T Monitoring of IOP for 24 hrs or longer emerging technoogy 0330T Tear film imaging emerging technoogy 0333T VEP, screening of VA, automated emerging technoogy 0341T Quantitative pupillometry w/ I&R emerging technoogy Covered Screening Services Reporting Codes g services reporting G0117 Glaucoma screening for high-risk patients furnished by a physician (ICD-10: Z13.5) $49.81 $47.32 $54.42 $53.33 $53.33 $52.26 G0118 Glaucoma screening for high-risk patients furnished under direct supervision of a physician (ICD-10: Z13.5) $39.80 $37.81 $43.48 $42.61 $42.61 $41.76 Surgical Procedures and Post-operative Comanagement Services tive comanagement Incision And Drainage of Abscess (EG, Carbuncle, cyst, furuncle, etc.); Simple or Single (10 DAYS PO) $ $ $ $ $ $ Facility Incision And Drainage of Abscess (EG, Carbuncle, cyst, furuncle, etc.); Simple or Single (10 DAYS PO) $91.64 $87.06 $ $98.12 $98.12 $ Incision And Drainage of Abscess (EG, Carbuncle, cyst, furuncle, etc.); Complicated or Multiple (10 DAYS PO) $ $ $ $ $ $ Facility Incision And Drainage of Abscess (EG, Carbuncle, cyst, furuncle, etc.); Complicated or Multiple (10 DAYS PO) $ $ $ $ $ $ Incision And Removal of Foreign Body, Subcutaneous Tissues; Simple (10 DAYS PO) $ $ $ $ $ $ Facility Incision And Removal of Foreign Body, Subcutaneous Tissues; Simple (10 DAYS PO) $97.56 $92.68 $ $ $ $ Incision or Drainage of Hematoma, Seroma or Fluid Collection (10 DAYS PO) $ $ $ $ $ $ Facility Incision or Drainage of Hematoma, Seroma or Fluid Collection (10 DAYS PO) $ $ $ $ $ $ Puncture Aspiration of Abscess, Hematoma, Bulla, or Cyst (10 DAYS PO) $ $ $ $ $ $ Facility Puncture Aspiration of Abscess, Hematoma, Bulla, or Cyst (10 DAYS PO) $91.12 $86.56 $99.54 $97.55 $97.55 $ Biopsy of skin, subcutan. tissue and/or mucous membrane (including simple closure), unless listed; single lesion (0 Day) $94.77 $90.03 $ $ $ $99.44 Facility Biopsy of skin, subcutan. tissue and/or mucous membrane (including simple closure), unless listed; single lesion (0 Day) $47.32 $44.95 $51.69 $50.66 $50.66 $ Biopsy of skin, etc; each separate/additional lesion (List separately in addition to code for primary procedure) $30.86 $29.32 $33.72 $33.04 $33.04 $32.38 Facility Biopsy of skin, etc; each separate/additional lesion (List separately in addition to code for primary procedure) $24.30 $23.09 $26.55 $26.02 $26.02 $ Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions (10 DAYS PO) $81.39 $77.32 $88.92 $87.14 $87.14 $85.39 Facility Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions (10 DAYS PO) $68.90 $65.46 $75.28 $73.77 $73.77 $ Removal of skin tags, etc.; each additional ten lesions (List separately in addition to code for primary procedure) $18.15 $17.24 $19.83 $19.44 $19.44 $19.04 Facility Removal of skin tags, etc.; each additional ten lesions (List separately in addition to code for primary procedure) $16.28 $15.47 $17.79 $17.43 $17.43 $ Shaving of Epidermal or Dermal Lesion, Single,.. Eyelids; Diameter 0.5 CM OR Less (0 DAY PO) $ $98.30 $ $ $ $ Facility Shaving of Epidermal or Dermal Lesion, Single,.. Eyelids; Diameter 0.5 CM OR Less (0 DAY PO) $46.02 $43.72 $50.28 $49.28 $49.28 $ Shaving of Epidermal or Dermal Lesion, Single; Diameter 0.6 to 1.0 CM (0 DAY PO) $ $98.07 $ $ $ $ Facility Shaving of Epidermal or Dermal Lesion, Single; Diameter 0.6 to 1.0 CM (0 DAY PO) $63.89 $60.70 $69.81 $68.41 $68.41 $ Excision, Other Benign Lesion including Margins, Eyelids; Diameter 0.5 CM or Less (10 DAYS PO) $ $ $ $ $ $ Facility Excision, Other Benign Lesion including Margins, Eyelids; Diameter 0.5 CM or Less (10 DAYS PO) $96.48 $91.66 $ $ $ $ PQRS LC***** EHR + PQRS LC******

2 11441 Excision, Other Benign Lesion including Margins, Eyelids; Diameter 0.6 to 1.0 CM (10 DAYS PO $ $ $ $ $ $ Facility Excision, Other Benign Lesion including Margins, Eyelids; Diameter 0.6 to 1.0 CM (10 DAYS PO $ $ $ $ $ $ Excision, Other Benign Lesion including Margins, Eyelids; Diameter 1.1 to 2.0 CM (10 DAYS PO) $ $ $ $ $ $ Facility Excision, Other Benign Lesion including Margins, Eyelids; Diameter 1.1 to 2.0 CM (10 DAYS PO) $ $ $ $ $ $ Excision, Other Benign Lesion including Margins, Eyelids; Diameter 2.1 to 3.0 CM (10 DAYS PO) $ $ $ $ $ $ Facility Excision, Other Benign Lesion including Margins, Eyelids; Diameter 2.1 to 3.0 CM (10 DAYS PO) $ $ $ $ $ $ Excision, Other Benign Lesion including Margins, Eyelids; Diameter 3.1 to 4.0 CM (10 DAYS PO) $ $ $ $ $ $ Facility Excision, Other Benign Lesion including Margins, Eyelids; Diameter 3.1 to 4.0 CM (10 DAYS PO) $ $ $ $ $ $ Excision, Other Benign Lesion including Margins, Eyelids; Diameter over 4.0 CM (10 DAYS PO) $ $ $ $ $ $ Facility Excision, Other Benign Lesion including Margins, Eyelids; Diameter over 4.0 CM (10 DAYS PO) $ $ $ $ $ $ Injection into Skin Lesions; up to and including 7 Lesions (0 DAYS POSTOP) $51.33 $48.76 $56.07 $54.95 $54.95 $53.84 Facility Injection into Skin Lesions; up to and including 7 Lesions (0 DAYS POSTOP) $30.41 $28.89 $33.22 $32.56 $32.56 $ Simple Repair of Superficial Wounds of Eyelids; Diameter 2.5 CM or Less (10 DAYS PO) $ $96.17 $ $ $ $ Facility Simple Repair of Superficial Wounds of Eyelids; Diameter 2.5 CM or Less (10 DAYS PO) $54.09 $51.39 $59.10 $57.91 $57.91 $ Simple Repair of Superficial Wounds of Eyelids; Diameter 2.6 to 5.0 CM (10 DAYS PO) $ $ $ $ $ $ Facility Simple Repair of Superficial Wounds of Eyelids; Diameter 2.6 to 5.0 CM (10 DAYS PO) $57.25 $54.39 $62.55 $61.30 $61.30 $ Simple Repair of Superficial Wounds of Eyelids; Diameter 5.1 to 7.5 CM (10 DAYS PO) $ $ $ $ $ $ Facility Simple Repair of Superficial Wounds of Eyelids; Diameter 5.1 to 7.5 CM (10 DAYS PO) $73.80 $70.11 $80.63 $79.02 $79.02 $ Layer Closure of Wounds of Eyelids; Diameter 2.5 CM or Less (10 DAYS PO) $ $ $ $ $ $ Facility Layer Closure of Wounds of Eyelids; Diameter 2.5 CM or Less (10 DAYS PO) $ $ $ $ $ $ Layer Closuer of Wounds of Eyelids; Diameter 2.6 to 5.0 CM (10 DAYS PO) $ $ $ $ $ $ Facility Layer Closuer of Wounds of Eyelids; Diameter 2.6 to 5.0 CM (10 DAYS PO) $ $ $ $ $ $ Layer Closure of Wounds of Eyelids; Diameter 5.1 to 7.5 CM (10 DAYS PO) $ $ $ $ $ $ Facility Layer Closure of Wounds of Eyelids; Diameter 5.1 to 7.5 CM (10 DAYS PO) $ $ $ $ $ $ Layer Closuer of Wounds of Eyelids; Diameter 7.6 to 12.5 CM (10 DAYS PO) $ $ $ $ $ $ Facility Layer Closuer of Wounds of Eyelids; Diameter 7.6 to 12.5 CM (10 DAYS PO) $ $ $ $ $ $ Initial Treatment, First Degree Burn, When no More than Local Treatment (0 DAYS PO) $64.85 $61.61 $70.85 $69.44 $69.44 $68.05 Facility Initial Treatment, First Degree Burn, When no More than Local Treatment (0 DAYS PO) $45.18 $42.92 $49.36 $48.37 $48.37 $ Dressings and/or Debridement, Initial or Subs; Office or Hospital, Small (0 DAYS PO) $75.29 $71.53 $82.26 $80.62 $80.62 $79.01 Facility Dressings and/or Debridement, Initial or Subs; Office or Hospital, Small (0 DAYS PO) $51.56 $48.98 $56.33 $55.20 $55.20 $ Destruction (eg,laser SX,ElectroSX,CryoSX,ChemoSX,SX Curettement), Premalignant (eg, actinic keratoses); 1ST (10 DAYS PO) $61.72 $58.63 $67.42 $66.08 $66.08 $64.76 Facility Destruction (eg,laser SX,ElectroSX,CryoSX,ChemoSX,SX Curettement), Premalignant (eg, actinic keratoses); 1ST (10 DAYS PO) $50.17 $47.66 $54.81 $53.72 $53.72 $ Destruction; Second Thru 14 Lesions, Each (LIST SEPARATELY IN ADDITION TO 17000) $5.17 $4.91 $5.65 $5.53 $5.53 $5.42 Facility Destruction; Second Thru 14 Lesions, Each (LIST SEPARATELY IN ADDITION TO 17000) $2.36 $2.24 $2.58 $2.53 $2.53 $ Destruction; 15 or More Lesions (DO NOT USE WITH OR 17003)(10 DAYS POST OP) $ $ $ $ $ $ Facility Destruction; 15 or More Lesions (DO NOT USE WITH OR 17003)(10 DAYS POST OP) $95.38 $90.61 $ $ $ $ Destruction (eg,laser SX,ElectroSX,CryoSX,ChemoSX,SX curettement),benign LESIONS other than skin tags 1-14 (10 DAYS PO) $ $95.80 $ $ $ $ Facility Destruction (eg,laser SX,ElectroSX,CryoSX,ChemoSX,SX curettement),benign LESIONS other than skin tags 1-14 (10 DAYS PO) $65.25 $61.99 $71.29 $69.86 $69.86 $ Destruction; 15 or More Lesions (10 DAYS PO) $ $ $ $ $ $ Facility Destruction; 15 or More Lesions (10 DAYS PO) $80.81 $76.77 $88.29 $86.51 $86.51 $ Chemical Cauterization of Granulation Tissue (Proud Flesh, Sinus or Fistula) (0 DAYS PO) $72.16 $68.55 $78.83 $77.26 $77.26 $75.72 Facility Chemical Cauterization of Granulation Tissue (Proud Flesh, Sinus or Fistula) (0 DAYS PO) $35.32 $33.55 $38.58 $37.81 $37.81 $ Introduction of Needle or Intracatheter, Vein NC NC NC NC NC NC Facility Introduction of Needle or Intracatheter, Vein NC NC NC NC NC NC Venipuncture, Age 3 Years or Older, Necessitating Physician's Skill for Diagnostic/Therapeutic $15.79 $15.00 $17.25 $16.91 $16.91 $16.57 Facility Venipuncture, Age 3 Years or Older, Necessitating Physician's Skill for Diagnostic/Therapeutic $9.24 $8.78 $10.10 $9.89 $9.89 $ Collection of Venous Blood by Venipuncture Not paid separately Collection of Capillary Blood Specimen (EG, Finger, heel, ear stick) Not paid separately Injection, Anesthetic Agent; Trigeminal Nerve, any Division or Branch (0 DAYS PO) $ $ $ $ $ $ Facility Injection, Anesthetic Agent; Trigeminal Nerve, any Division or Branch (0 DAYS PO) $68.57 $65.14 $74.91 $73.42 $73.42 $ Injection, Anesthetic Agent; Facial Nerve (0 DAYS PO) $ $ $ $ $ $ Facility Injection, Anesthetic Agent; Facial Nerve (0 DAYS PO) $76.04 $72.24 $83.08 $81.42 $81.42 $ $74.24 $70.53 $81.11 $79.49 $79.49 $77.90 Facility Injection Anesthetic Agent; Other Peripheral Nerve or Branch (0 DAYS PO) $44.27 $42.06 $48.37 $47.40 $47.40 $ Chemodenervation of Muscle(s)'; Innervated by Facial Nerve (EG, For Blepharospasm)(10 DAYS PO) $ $ $ $ $ $ Facility Chemodenervation of Muscle(s)'; Innervated by Facial Nerve (EG, For Blepharospasm)(10 DAYS PO) $ $ $ $ $ $ Remove Foreign Body - Surface (0 DAYS POSTOP) $52.54 $49.91 $57.40 $56.25 $56.25 $55.12 Facility Remove Foreign Body - Surface (0 DAYS POSTOP) $42.24 $40.13 $46.15 $45.23 $45.23 $ Remove Foreign Body - Subconjunctival (0 DAYS POSTOP) $64.37 $61.15 $70.32 $68.92 $68.92 $67.54 Facility Remove Foreign Body - Subconjunctival (0 DAYS POSTOP) $50.95 $48.40 $55.66 $54.54 $54.54 $ Remove Foreign Body - Corneal NO Slit Lamp (0 DAYS POSTOP) $54.38 $51.66 $59.41 $58.22 $58.22 $57.06 Facility Remove Foreign Body - Corneal NO Slit Lamp (0 DAYS POSTOP) $40.64 $38.61 $44.40 $43.52 $43.52 $ Remove Foreign Body - Corneal W/Slit Lamp (0 DAYS POSTOP) $62.50 $59.38 $68.29 $66.92 $66.92 $65.58 Facility Remove Foreign Body - Corneal W/Slit Lamp (0 DAYS POSTOP) $50.01 $47.51 $54.64 $53.54 $53.54 $ Repair of Laceration; Conjunctiva, ETC. (10 DAYS POSTOP) $ $ $ $ $ $ Facility Repair of Laceration; Conjunctiva, ETC. (10 DAYS POSTOP) $ $ $ $ $ $ Repair of Laceration; Application of Tissue Glue, Wounds of Cornea and/or Sclera (90 DAYS PO) $ $ $ $ $ $ Facility Repair of Laceration; Application of Tissue Glue, Wounds of Cornea and/or Sclera (90 DAYS PO) $93.72 $89.03 $ $ $ $ Scraping of Cornea (0 DAYS POSTOP) $ $ $ $ $ $ Facility Scraping of Cornea (0 DAYS POSTOP) $98.12 $93.21 $ $ $ $ Removal of Epithelium; with or without Chemocauterization (0 DAYS POSTOP) $74.41 $70.69 $81.29 $79.67 $79.67 $78.07 Facility Removal of Epithelium; with or without Chemocauterization (0 DAYS POSTOP) $65.66 $62.38 $71.74 $70.30 $70.30 $ Removal of Epithelium with Application of Chelating Agent (0 DAYS POSTOP) $ $ $ $ $ $ Facility Removal of Epithelium with Application of Chelating Agent (0 DAYS POSTOP) $ $ $ $ $ $ Post-Op RK (90 DAYS PO) Placement of amniotic membrane on the ocular surface for would healing; self-retaining (10 DAYS POSTOP) $1, $1, $1, $1, $1, $1, Facility Placement of amniotic membrane on the ocular surface for would healing; self-retaining (10 DAYS POSTOP) $56.34 $53.52 $61.55 $60.32 $60.32 $ Paracentesis of anterior chamber of eye; with removal of aqueous (O DAYS POSTOP) $ $ $ $ $ $ Facility Paracentesis of anterior chamber of eye; with removal of aqueous (O DAYS POSTOP) $88.08 $83.68 $96.23 $94.31 $94.31 $ ALT (Trabeculoplasty) (10 DAYS POSTOP) $ $ $ $ $ $ Facility ALT (Trabeculoplasty) (10 DAYS POSTOP) $ $ $ $ $ $ Post-Op Trabeculoplasty (10 DAYS PO) $25.34 $24.07 $27.68 $27.13 $27.13 $26.58 Facility Post-Op Trabeculoplasty (10 DAYS PO) $22.46 $21.34 $24.54 $24.05 $24.05 $ Post-Op Trabeculectomy (90 DAYS PO) $ $ $ $ $ $ Iridotomy/Iridectomy - Laser (90 DAYS PO) $ $ $ $ $ $ Facility Iridotomy/Iridectomy - Laser (90 DAYS PO) $ $ $ $ $ $ Iridosplasty By Photocoagulation (One or More Sessions) (90 DAYS PO) $88.72 $84.28 $96.92 $94.98 $94.98 $93.08 Facility Iridosplasty By Photocoagulation (One or More Sessions) (90 DAYS PO) $80.29 $76.27 $87.71 $85.96 $85.96 $ Destruction of Cyst or Lesion Iris/Ciliary Body (Nonexcisional) (90 DAYS POSTOP) $98.70 $93.76 $ $ $ $ Facility Destruction of Cyst or Lesion Iris/Ciliary Body (Nonexcisional) (90 DAYS POSTOP) $91.08 $86.52 $99.50 $97.51 $97.51 $95.56

3 66821 YAG Capsulotomy (90 DAYS POSTOP) $ $ $ $ $ $ Facility YAG Capsulotomy (90 DAYS POSTOP) $ $ $ $ $ $ POST-OP YAG (90 DAYS POSTOP) $61.35 $58.28 $67.02 $65.68 $65.68 $64.37 Facility POST-OP YAG (90 DAYS POSTOP) $58.10 $55.19 $63.47 $62.20 $62.20 $60.96 Facility Post-Op Extracapsular Cataract Removal W/ Insertion of IOL (90 DAYS PO) $ $ $ $ $ $ Facility Post-Op Intracapsular Cataract Extraction with Insertion of IOL (90 DAYS PO) $ $ $ $ $ $ Facility Post-Op Extracapsular Cataract Removal w/ Insertion of IOL (90 DAYS POSTOP) $ $ $ $ $ $ Facility Post-Op Second Surgery - Cataract (90 DAYS POSTOP) $ $ $ $ $ $ Facility Exchange Of IOL (90 DAY POSTOP) $ $ $ $ $ $ Fine needle aspiration of orbital contents (0 Days PO) $ $95.64 $ $ $ $ Retrobulbar injection; medication (0 Days PO) $75.80 $72.01 $82.81 $81.16 $81.16 $79.53 Facility Retrobulbar injection; medication (0 Days PO) $70.50 $66.98 $77.03 $75.49 $75.49 $ Retrobulbar injection; alcohol (0 Days PO) $84.41 $80.19 $92.22 $90.38 $90.38 $88.57 Facility Retrobulbar injection; alcohol (0 Days PO) $77.85 $73.96 $85.05 $83.35 $83.35 $ Injection of medication or other substance into Tenon's capsule (0 Days PO) $91.87 $87.28 $ $98.36 $98.36 $96.39 Facility Injection of medication or other substance into Tenon's capsule (0 Days PO) $85.31 $81.04 $93.20 $91.33 $91.33 $ Blepharotomy, Drainage of Abscess, Eyelid (10 DAYS POSTOP) $ $ $ $ $ $ Facility Blepharotomy, Drainage of Abscess, Eyelid (10 DAYS POSTOP) $ $ $ $ $ $ Canthotomy (10 DAYS POSTOP) $ $ $ $ $ $ Facility Canthotomy (10 DAYS POSTOP) $ $96.78 $ $ $ $ Excision of Chalazion (10 DAYS POSTOP) $ $ $ $ $ $ Facility Excision of Chalazion (10 DAYS POSTOP) $97.84 $92.95 $ $ $ $ Excision of Chalazion - Multiple (10 DAYS POSTOP) $ $ $ $ $ $ Facility Excision of Chalazion - Multiple (10 DAYS POSTOP) $ $ $ $ $ $ Excision of Chalazion- Multiple - Different Lids (10 DAYS POSTOP) $ $ $ $ $ $ Facility Excision of Chalazion- Multiple - Different Lids (10 DAYS POSTOP) $ $ $ $ $ $ Biopsy of Eyelid (0 DAYS PO) Incisional biopsy of eyelid skin including lid margin (0 DAYS POSTOP) $ $ $ $ $ $ Facility Biopsy of Eyelid (0 DAYS PO) Incisional biopsy of eyelid skin including lid margin (0 DAYS POSTOP) $69.27 $65.81 $75.68 $74.16 $74.16 $ Correct Trichiasis-Epilation (0 DAYS POSTOP) $47.24 $44.88 $51.61 $50.58 $50.58 $49.57 Facility Correct Trichiasis-Epilation (0 DAYS POSTOP) $50.36 $47.84 $55.02 $53.91 $53.91 $ Correct Trichiasis - Epilation - Cryotherapy or Laser (10 DAYS POSTOP) $ $ $ $ $ $ Facility Correct Trichiasis - Epilation - Cryotherapy or Laser (10 DAYS POSTOP) $ $ $ $ $ $ Excision of Lesion on Lid (10 DAYS POSTOP) $ $ $ $ $ $ Facility Excision of Lesion on Lid (10 DAYS POSTOP) $ $ $ $ $ $ Destruction of Lesion of Lid Margin (UP TO 1CM) (10 DAYS POSTOP) $ $ $ $ $ $ Facility Destruction of Lesion of Lid Margin (UP TO 1CM) (10 DAYS POSTOP) $ $ $ $ $ $ Temporary Closure of Eyelids by Suture (0 DAYS POSTOP) $ $ $ $ $ $ Facility Temporary Closure of Eyelids by Suture (0 DAYS POSTOP) $92.25 $87.64 $ $98.77 $98.77 $ Suture of Recent Wound Eyelid, LidMargin, Tarsus &/or Palpebral Conj (10 DAYS PO) $ $ $ $ $ $ Facility Suture of Recent Wound Eyelid, LidMargin, Tarsus &/or Palpebral Conj (10 DAYS PO) $ $ $ $ $ $ Suture of Recent Wound, Eyelid,Lid Margin,Tarsus&/or Palpebral Conj; Full Thickness (90 DAYS PO) $ $ $ $ $ $ Facility Suture of Recent Wound, Eyelid,Lid Margin,Tarsus&/or Palpebral Conj; Full Thickness (90 DAYS PO) $84.15 $79.94 $91.93 $90.09 $90.09 $ Remove FB - Eyelid (10 DAYS POSTOP) $ $ $ $ $ $ Facility Remove FB - Eyelid (10 DAYS POSTOP) $ $ $ $ $ $ Incision of Conj, Drainage of Cyst (10 DAYS POSTOP) $ $ $ $ $ $ Facility Incision of Conj, Drainage of Cyst (10 DAYS POSTOP) $ $98.92 $ $ $ $ Expression of Conj Follicles (eg, For Trachoma) (0 DAYS PO) $59.11 $56.15 $64.57 $63.28 $63.28 $62.02 Facility Expression of Conj Follicles (eg, For Trachoma) (0 DAYS PO) $48.81 $46.37 $53.33 $52.26 $52.26 $ Biopsy of Conj (0 DAYS POSTOP) $ $ $ $ $ $ Facility Biopsy of Conj (0 DAYS POSTOP) $92.26 $87.65 $ $98.79 $98.79 $ Excision of Lesion, Conj, Up To 1 CM (10 DAYS POSTOP) $ $ $ $ $ $ Facility Excision of Lesion, Conj, Up To 1 CM (10 DAYS POSTOP) $ $ $ $ $ $ Excision of Lesion, Conj, Over 1 CM (10 DAYS POSTOP) $ $ $ $ $ $ Facility Excision of Lesion, Conj, Over 1 CM (10 DAYS POSTOP) $ $ $ $ $ $ Destruction of Lesion, Conj (10 DAYS POSTOP) $ $ $ $ $ $ Facility Destruction of Lesion, Conj (10 DAYS POSTOP) $ $ $ $ $ $ Subconjunctival Injection (0 DAYS POSTOP) $38.74 $36.80 $42.32 $41.47 $41.47 $40.64 Facility Subconjunctival Injection (0 DAYS POSTOP) $33.12 $31.46 $36.18 $35.45 $35.45 $ Incision, Drainage Of Lacrimal SAC (10 DAYS POSTOP) $ $ $ $ $ $ Facility Incision, Drainage Of Lacrimal SAC (10 DAYS POSTOP) $ $ $ $ $ $ Snip Incision of Lacrimal Punctum (10 DAYS POSTOP) $94.70 $89.97 $ $ $ $99.37 Facility Snip Incision of Lacrimal Punctum (10 DAYS POSTOP) $92.20 $87.59 $ $98.72 $98.72 $ Correction of Everted Punctum, Cautery (10 DAYS PO) $ $ $ $ $ $ Facility Correction of Everted Punctum, Cautery (10 DAYS PO) $ $ $ $ $ $ Closure of Lacrimal Punctum; Laser (10 DAYS POSTOP) $ $ $ $ $ $ Facility Closure of Lacrimal Punctum; Laser (10 DAYS POSTOP) $ $ $ $ $ $ Insertion of Lacrimal Plugs (10 DAYS POSTOP) $ $ $ $ $ $ Facility Insertion of Lacrimal Plugs (10 DAYS POSTOP) $ $ $ $ $ $ Dilation of Punctum (10 DAYS POSTOP) $92.38 $87.76 $ $98.90 $98.90 $96.92 Facility Dilation of Punctum (10 DAYS POSTOP) $80.51 $76.48 $87.95 $86.19 $86.19 $ Probing of Nasolacrimal Duct (10 DAYS POSTOP) $ $ $ $ $ $ Facility Probing of Nasolacrimal Duct (10 DAYS POSTOP) $ $ $ $ $ $ Facility Probing of Nasolacrimal Duct, Requiring General Anesthesia (10 DAYS POSTOP) $ $ $ $ $ $ Probing of Nasolacrimal Duct, W/ Insertion of Tube or Stent (10 DAYS POSTOP) $ $ $ $ $ $ Facility Probing of Nasolacrimal Duct, W/ Insertion of Tube or Stent (10 DAYS POSTOP) $ $ $ $ $ $ Probing of nasolacrimal duct, W/ transluminal baloon catheter dilation (10DAYS POSTOP) $ $ $ $ $ $ Facility Probing of nasolacrimal duct, W/ transluminal baloon catheter dilation (10DAYS POSTOP) $ $ $ $ $ $ Probing of Lacrimal Canaliculi (10 DAYS POSTOP) $ $ $ $ $ $ Facility Probing of Lacrimal Canaliculi (10 DAYS POSTOP) $ $ $ $ $ $ Pathology and Laboratory/Chemistry (Requires CLIA certification) 83861QW Microfluidic analysis utilizing an integrated collection and analysis device, tear osmolarity $22.50 Diagnostic Radiology Services B-scan and A-scan $ $ $ $ $ $ B-scan and A-scan- Technical Component only $71.49 $67.92 $78.11 $76.54 $76.54 $ TC B-scan and A-scan- Professional Component only $85.76 $81.47 $93.69 $91.82 $91.82 $ A-SCAN $93.58 $88.90 $ $ $ $ A-Scan - Professional Component Only $42.45 $40.33 $46.38 $45.45 $45.45 $ TC A-SCAN - Technical Component Only $51.13 $48.57 $55.86 $54.74 $54.74 $ B-Scan (W/Or W/Out A-Scan) $86.09 $81.79 $94.06 $92.17 $92.17 $90.33

4 B-Scan (W/Or W/Out A-Scan) - Professional Component Only $34.96 $33.21 $38.19 $37.43 $37.43 $ TC B-Scan (W/Or W/Out A-Scan) - Technical Component Only $51.13 $48.57 $55.86 $54.74 $54.74 $ Waterbath B-Scan $86.99 $82.64 $95.04 $93.14 $93.14 $ Waterbath B-Scan - Professional Component Only $52.44 $49.82 $57.29 $56.14 $56.14 $ TC Waterbath B-Scan - Technical Component Only $34.55 $32.82 $37.74 $36.98 $36.98 $ Pachymetry $14.18 $13.47 $15.49 $15.18 $15.18 $ Pachymetry - Professional Component Only $4.67 $4.44 $5.11 $5.00 $5.00 $ TC Pachymetry - Technical Component Only $9.51 $9.03 $10.38 $10.18 $10.18 $ Ophthalmic Biometry $71.77 $68.18 $78.41 $76.84 $76.84 $ Ophthalmic Biometry - Professional Component Only $41.83 $39.74 $45.70 $44.79 $44.79 $ TC Ophthalmic Biometry - Technical Component Only $29.94 $28.44 $32.71 $32.05 $32.05 $ Ophthalmic Biometry;IOL Calculation $76.45 $72.63 $83.52 $81.86 $81.86 $ Ophthalmic Biometry;IOL Calculation - Professional Component Only $46.51 $44.18 $50.81 $49.80 $49.80 $ TC Ophthalmic Biometry;IOL Calculation - Technical Component Only $29.94 $28.44 $32.71 $32.05 $32.05 $ Ultrasound FB Localization $72.53 $68.90 $79.24 $77.65 $77.65 $ Ultrasound FB Localization - Professional Component Only $41.20 $39.14 $45.01 $44.11 $44.11 $ TC Ultrasound FB Localization - Technical Component Only $31.33 $29.76 $34.22 $33.53 $33.53 $32.87 General Ophthalmological and Optometric Services New Patient Intermediate Exam $75.19 $71.43 $82.14 $80.50 $80.50 $78.89 Facility New Patient Intermediate Exam $46.15 $43.84 $50.42 $49.40 $49.40 $ New Patient Comprehensive Exam $ $ $ $ $ $ Facility New Patient Comprehensive Exam $96.32 $91.50 $ $ $ $ Established Patient Intermediate Exam $79.11 $75.15 $86.42 $84.70 $84.70 $83.01 Facility Established Patient Intermediate Exam $50.70 $48.17 $55.40 $54.29 $54.29 $ Established Patient Comprehensive Exam $ $ $ $ $ $ Facility Established Patient Comprehensive Exam $77.01 $73.16 $84.13 $82.46 $82.46 $ Refraction on-covered services Facility Exam and Evaluation, under general anesthesia, wi or w/o manipulation of globe; complete $ $ $ $ $ $ Facility Exam and Evaluation, under general anesthesia, wi or w/o manipulation of globe; limited $69.33 $65.86 $75.74 $74.22 $74.22 $ Gonioscopy (bilateral) $25.10 $23.85 $27.43 $26.88 $26.88 $26.34 Facility Gonioscopy (bilateral) $20.11 $19.10 $21.97 $21.53 $21.53 $ Corneal Topography $34.99 $33.24 $38.23 $37.47 $37.47 $ TC Corneal Topography - Technical Component only $15.60 $14.82 $17.04 $16.70 $16.70 $ Corneal Topography - Professional Component only $19.39 $18.42 $21.18 $20.76 $20.76 $ Sensorimotor Exam;Multiple Measures (bilateral) $60.28 $57.27 $65.86 $64.54 $64.54 $ TC Sensorimotor Exam;Multiple Measures - Technical Component only $23.41 $22.24 $25.58 $25.07 $25.07 $ Sensorimotor Exam;Multiple Measures - Professional Component only $36.87 $35.03 $40.28 $39.48 $39.48 $ Orthoptic & Pleoptic Training (bilateral) $48.51 $46.08 $52.99 $51.93 $51.93 $ TC Orthoptic & Pleoptic Training - Technical Component only $30.90 $29.36 $33.76 $33.09 $33.09 $ Orthoptic & Pleoptic Training - Professional Component only $17.61 $16.73 $19.24 $18.86 $18.86 $ Fitting of CL for treatment of ocular surface disease $36.18 $34.37 $39.53 $38.73 $38.73 $37.96 Facility Fitting of CL for treatment of ocular surface disease $32.44 $30.82 $35.44 $34.73 $34.73 $ Fitting of CL for management of keratoconus, initial fitting $ $ $ $ $ $ Facility Fitting of CL for management of keratoconus, initial fitting $ $95.12 $ $ $ $ VF - Screening (bilateral) $31.02 $29.47 $33.89 $33.21 $33.21 $ TC VF - Screening - Technical Component only $15.29 $14.53 $16.71 $16.38 $16.38 $ VF - Screening - Professional Component only $15.73 $14.94 $17.18 $16.84 $16.84 $ VF - Intermediate (bilateral) $43.96 $41.76 $48.02 $47.06 $47.06 $ TC VF - Intermediate - Technical Component only $23.09 $21.94 $25.23 $24.73 $24.73 $ VF - Intermediate - Professional Component only $20.87 $19.83 $22.80 $22.34 $22.34 $ VF - Threshold (bilateral) $58.78 $55.84 $64.22 $62.93 $62.93 $ TC VF - Threshold - Technical Component only $31.84 $30.25 $34.79 $34.10 $34.10 $ VF - Threshold - Professional Component only $26.95 $25.60 $29.44 $28.85 $28.85 $ Serial Tonometry (bilateral) $73.02 $69.37 $79.78 $78.18 $78.18 $76.61 Facility Serial Tonometry (bilateral) $32.75 $31.11 $35.78 $35.06 $35.06 $ Scanning Laser - Anterior Seg (bilateral) $32.18 $30.57 $35.16 $34.45 $34.45 $ TC Scanning Laser - Anterior Seg (bilateral) (Technical Component) $13.73 $13.04 $15.00 $14.70 $14.70 $ Scanning Laser - Anterior Seg (bilateral) (Professional Component) $18.45 $17.53 $20.16 $19.76 $19.76 $ Scanning Laser - Optic Nerve $40.99 $38.94 $44.78 $43.88 $43.88 $ TC Scanning Laser - Optic Nerve (Technical Component) $14.04 $13.34 $15.34 $15.03 $15.03 $ Scanning Laser - Optic Nerve (Professional Component) $26.95 $25.60 $29.44 $28.85 $28.85 $ Scanning Laser - Retina $41.92 $39.82 $45.79 $44.87 $44.87 $ TC Scanning Laser - Retina (Technical Component) $14.35 $13.63 $15.67 $15.36 $15.36 $ Scanning Laser - Retina (Professional Component) $27.57 $26.19 $30.12 $29.52 $29.52 $ Ophthalmic Biometry by Partial Coherence Interferometry w/ Lens Calculation (bilateral) $81.76 $77.67 $89.32 $87.54 $87.54 $ TC Ophthalmic Biometry by Partial Coherence Interferometry w/ Lens Calculation - Technical Component only (unilateral) $51.82 $49.23 $56.61 $55.49 $55.49 $ Ophthalmic Biometry by Partial Coherence Interferometry w/ Lens Calculation - Professional Component only $29.94 $28.44 $32.71 $32.05 $32.05 $ Provocative Glaucoma Test (bilateral) $57.84 $54.95 $63.19 $61.93 $61.93 $60.69 Facility Provocative Glaucoma Test (bilateral) $25.99 $24.69 $28.39 $27.83 $27.83 $ Corneal hysteresis determination, by air impulse stimulation (unilateral or bilateral) $14.18 $13.47 $15.49 $15.18 $15.18 $14.88 Facility TC Corneal hysteresis determination, by air impulse stimulation (unilateral or bilateral) - Technical Component only $5.92 $5.62 $6.46 $6.34 $6.34 $ Corneal hysteresis determination, by air impulse stimulation (unilateral or bilateral) - Professional Component only $8.26 $7.85 $9.03 $8.84 $8.84 $ Ophthalmoscopy - Extended (unilateral) $25.46 $24.19 $27.82 $27.27 $27.27 $26.73 Facility Ophthalmoscopy - Extended (unilateral) $20.46 $19.44 $22.36 $21.91 $21.91 $ Ophthalmoscopy - Subsequent (unilateral) $23.36 $22.19 $25.52 $25.01 $25.01 $24.52 Facility Ophthalmoscopy - Subsequent (unilateral) $18.36 $17.44 $20.06 $19.65 $19.65 $ Remote imaging for detection of retinal disease, (unilateral or bilateral) $12.79 $12.15 $13.97 $13.70 $13.70 $ Remote imaging for monitoring and management of active retinal disease (unilateral or bilateral) $31.96 $30.36 $34.91 $34.21 $34.21 $ TC Remote imaging for monitoring and management of active retinal disease (unilateral or bilateral) - Technical Component only $11.85 $11.26 $12.95 $12.68 $12.68 $ Remote imaging for monitoring and management of active retinal disease (unilateral or bilateral) - Professional Component only $20.11 $19.10 $21.97 $21.53 $21.53 $ Fluorescein Angioscopy w/ Interpretation and report (unilateral) $53.92 $51.22 $58.90 $57.73 $57.73 $56.58 Facility Fluorescein Angioscopy w/ Interpretation and report (unilateral) $32.38 $30.76 $35.37 $34.66 $34.66 $ Fluorescein Angiography w/interpretation and report (unilateral) $ $95.16 $ $ $ $ TC Fluorescein Angiography w/interpretation and report - Technical Component only $54.94 $52.19 $60.02 $58.82 $58.82 $ Fluorescein Angiography w/interpretation and report - Professional Component only $45.23 $42.97 $49.42 $48.43 $48.43 $ Indocyanine-Green Angiography w/interpretation and report (unilateral) $ $ $ $ $ $ TC Indocyanine-Green Angiography w/interpretation and report - Technical Component only $ $ $ $ $ $ Indocyanine-Green Angiography w/interpretation and report - Professional Component only $61.53 $58.45 $67.22 $65.87 $65.87 $ Fundus Photos (bilateral) $71.31 $67.74 $77.90 $76.35 $76.35 $ TC Fundus Photos - Technical Component only $48.07 $45.67 $52.52 $51.47 $51.47 $50.44

5 Fundus Photos - Professional Component only $23.24 $22.08 $25.39 $24.89 $24.89 $ Ophthalmodynamometry (bilateral) $17.14 $16.28 $18.72 $18.34 $18.34 $17.97 Facility Ophthalmodynamometry (bilateral) $10.59 $10.06 $11.57 $11.34 $11.34 $ Needle Oculoelectromyography (bilateral) $73.30 $69.64 $80.09 $78.49 $78.49 $ TC Needle Oculoelectromyography - Technical Component only $31.52 $29.94 $34.43 $33.74 $33.74 $ Needle Oculoelectromyography - Professional Component only $41.77 $39.68 $45.63 $44.72 $44.72 $ Electro-Oculography w/ Interpretation and report (bilateral) $84.22 $80.01 $92.01 $90.17 $90.17 $ TC Electro-Oculography w/ Interpretation and report - Technical Component only $44.01 $41.81 $48.08 $47.12 $47.12 $ Electro-Oculography w/ Interpretation and report - Professional Component only $40.21 $38.20 $43.93 $43.06 $43.06 $ Electroretinography w/ interpretation and report (bilateral) $ $ $ $ $ $ TC Electroretinography w/ interpretation and report - Technical Component only $82.72 $78.58 $90.37 $88.56 $88.56 $ Electroretinography w/ interpretation and report - Professional Component only $52.39 $49.77 $57.24 $56.09 $56.09 $ Color Vision Exam (bilateral) $49.47 $47.00 $54.05 $52.97 $52.97 $ TC Color Vision Exam - Technical Component only $40.58 $38.55 $44.33 $43.45 $43.45 $ Color Vision Exam - Professional Component only $8.89 $8.45 $9.72 $9.52 $9.52 $ Dark Adaptation Exam (bilateral) $55.09 $52.34 $60.19 $58.98 $58.98 $ TC Dark Adaptation Exam - Technical Component only $43.08 $40.93 $47.07 $46.13 $46.13 $ Dark Adaptation Exam - Professional Component only $12.02 $11.42 $13.13 $12.87 $12.87 $ External Ocular Photos (bilateral) $18.32 $17.40 $20.01 $19.61 $19.61 $ TC External Ocular Photos - Technical Component only $15.29 $14.53 $16.71 $16.38 $16.38 $ External Ocular Photos - Professional Component only $3.03 $2.88 $3.31 $3.24 $3.24 $ Anterior SEG Photos w/ Endothelial Cell analysis (bilateral) $35.53 $33.75 $38.81 $38.04 $38.04 $ TC Anterior SEG Photos w/ Endothelial Cell analysis - Technical Component only $14.04 $13.34 $15.34 $15.03 $15.03 $ Anterior SEG Photos w/ Endothelial Cell analysis - Professional Component only $21.49 $20.42 $23.48 $23.01 $23.01 $ Anterior SEG Photos w/ Fluores Angiography (bilateral) $ $ $ $ $ $ TC Anterior SEG Photos w/ Fluores Angiography (bilateral) Technical Component only $79.28 $75.32 $86.62 $84.88 $84.88 $ Anterior SEG Photos w/fluores Angiography (bilateral) Professional Component only $44.91 $42.66 $49.06 $48.08 $48.08 $ RX/Design/Fit on-covered services " APHAKIA - ONE EYE $93.89 $89.20 $ $ $ $98.52 Facility " APHAKIA - ONE EYE $54.24 $51.53 $59.26 $58.08 $58.08 $ " APHAKIA - BOTH EYES $ $ $ $ $ $ Facility " APHAKIA - BOTH EYES $61.93 $58.83 $67.65 $66.30 $66.30 $ " CORNEOSCLERAL LENS $89.42 $84.95 $97.69 $95.74 $95.74 $93.83 Facility " CORNEOSCLERAL LENS $46.02 $43.72 $50.28 $49.28 $49.28 $ RX/Design/Fit BY Tech on-covered services " APHAKIA - ONE EYE $66.05 $62.75 $72.16 $70.73 $70.73 $69.31 Facility " APHAKIA - ONE EYE $21.40 $20.33 $23.38 $22.91 $22.91 $ " APHAKIA - BOTH EYES $83.65 $79.47 $91.39 $89.56 $89.56 $87.77 Facility " APHAKIA - BOTH EYES $32.13 $30.52 $35.10 $34.40 $34.40 $ RX/Design/Fit Corneoscleral Lens $68.86 $65.42 $75.23 $73.73 $73.73 $72.25 Facility RX/Design/Fit Corneoscleral Lens $21.71 $20.62 $23.71 $23.24 $23.24 $ Modification of Lens $36.83 $34.99 $40.24 $39.43 $39.43 $ Replacement of Lens $30.90 $29.36 $33.76 $33.09 $33.09 $ FITTING - MONOFOCAL on-covered services FITTING - BIFOCAL on-covered services FITTING - MULTIFOCAL on-covered services FITTING - APHAKIA - MONOFOCAL on-covered services FITTING-APHAKIA - MULTIFOCAL on-covered services LV AID - SINGLE ELEMENT on-covered services LV AID - COMPOUND on-covered services REPAIR & REFIT on-covered services REPAIR & REFIT - APHAKIA on-covered services UNLISTED OPHTHALMIC SERVICE uires documentation Visual evoked potential (VEP) testing central nervous system, checkerboard or flash $ $ $ $ $ $ TC Visual evoked potential (VEP) testing central nervous system, checkerboard or flash $97.70 $92.82 $ $ $ $ Visual evoked potential (VEP) testing central nervous system, checkerboard or flash $18.14 $17.23 $19.81 $19.42 $19.42 $ Therapeutic procedure(s), group (2 or more individuals) $16.62 $15.79 $18.16 $17.79 $17.79 $ Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities), each 15 min. $32.60 $30.97 $35.62 $34.90 $34.90 $34.20 Special Services, Procedures and Reports Postoperative Follow-up Visit (INCLUDED IN SX PACKAGE) Included in post-op global package OTHER THAN REGULARLY SCHEDULED OFFICE HOURS non-covered services DURING REGULARLY SCHEDULED EVENING, WEEKEND OR HOLIDAY OFFICE HOURS non-covered services SERVICES TYPICALLY PROVIDED IN OFFICE, PATIENT REQUEST OUT-OF-OFFICE non-covered services EMERGENCY BASIS, IN-OFFICE, DISRUPTS SCHEDULED SERVICES non-covered services EMERGENCY BASIS, OUT-OF-OFFICE, DISRUPTS SCHEDULED SERVICES non-covered services Supplies and materials (except spectacles), provided by physician over & above usually included items non-covered services Educational supplies, such as books, tapes & pamphlets, provided by the physician at cost of physician non-covered services Medical testimony non-covered services Special reports such as insurance forms, more than the info conveyed in the usual medical communications or standard form non-covered services Visual function screening, automated or semi-automated bilateral quanititative determiniation of VA (Stand alone code) non-covered services Screening test of VA, quantitative, bilateral non-covered services Ocular photoscreening with interpretation and report, bilateral non-covered services ********* ALWAYS REFER TO YOUR 2016 CPT CODING MANUAL FOR COMPLETE DESCRIPTIONS OF SERVICES. ********* CPT COPYRIGHT OF AMERICAN MEDICAL ASSOCIATION * PAR FEE APPLIES TO PROVIDERS CONTRACTED AS PARTICIPATING ** NON PAR FEE APPLIES TO PROVIDERS CONTRACTED AS NON-PARTICIPATING WHO ACCEPTS ASSIGNMENT ON A CLAIM BY CLAIM BASIS *** LC LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. **** EHR LC LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. ***** PQRS LC LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. ****** EHR + PQRS LC LIMITING CHARGE REDUCED FOR EPs THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. VISION SERVICES (HCPCS Level II) JC JC JD DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS STANDARD (DMEPOS) OK/AR/TX CO KS/MO V2020 FRAMES $63.94 $69.77 $62.73 V2025 DELUXE FRAMES

6 V2100 SV PL +/- 4.00, NO CYLINDER $45.64 $49.60 $37.20 V2101 SV , NO CYLINDER $52.27 $52.27 $39.20 V2102 SV , NO CYLINDER $58.09 $73.52 $55.14 V2103 SV PL +/- 4.00, W/CYL $34.57 $39.98 $32.30 V2104 SV PL +/- 4.00, W/CYL $40.87 $45.57 $35.77 V2105 SV PL +/- 4.00, W/CYL $40.01 $38.95 $38.95 V2106 SV PL +/- 4.00, W/CYL 6.00> $47.81 $43.22 $43.22 V2107 SV , W/CYL $51.53 $44.33 $41.10 V2108 SV , W/CYL $50.57 $53.94 $42.56 V2109 SV , W/CYL $48.48 $47.08 $47.08 V2110 SV , W/CYL >6.00 $46.57 $46.46 $46.46 V2111 SV , W/CYL PL $54.52 $48.43 $48.43 V2112 SV , W/CYL $70.50 $52.87 $52.87 V2113 SV , W/CYL $75.88 $60.40 $59.59 V2114 SV 12.25> ANY CYLINDER $86.06 $79.25 $64.55 V2115 SV LENTICULAR (MYODISC) $93.66 $83.74 $70.25 V2118 SV ANISEIKONIC LENS $69.64 $69.64 $69.64 V2121 LENTICULAR LENS, PER LENS, SINGLE $95.87 $74.30 $71.90 V2199 SV NOT OTHERWISE CLASSIFIED V2200 BF PL +/-4.00, NO CYLINDER $56.23 $52.17 $50.33 V2201 BF , NO CYLINDER $59.22 $61.20 $55.34 V2202 BF , NO CYLINDER $67.29 $80.92 $62.44 V2203 BF PL +/-4.00, W/CYL PL $55.23 $52.08 $49.79 V2204 BF PL +/-4.00, W/CYL $56.20 $54.12 $51.82 V2205 BF PL +/-4.00, W/CYL $58.64 $63.07 $55.52 V2206 BF PL +/-4.00, W/CYL >6.00 $59.96 $59.65 $59.65 V2207 BF , W/CYL PL $55.86 $60.79 $54.26 V2208 BF , W/CYL $61.99 $65.39 $59.42 V2209 BF , W/CYL $61.32 $66.26 $68.49 V2210 BF , W/CYL >6.00 $70.10 $70.66 $67.63 V2211 BF , W/CYL $70.13 $93.51 $70.13 V2212 BF , W/CYL $72.42 $96.56 $72.42 V2213 BF , W/CYL $77.39 $97.54 $73.16 V2214 BF 12.25> ANY CYLINDER $79.52 $92.71 $81.87 V2215 BF LENTICULAR (MYODISC) $90.68 $82.60 $80.73 V2218 BF ANISEIKONIC LENS $96.06 $96.06 $97.12 V2219 BF SEG OVER 28mm $48.83 $56.38 $49.12 V2220 BF ADD OVER 3.25d $44.70 $35.48 $45.73 V2221 LENTICULAR LENS, PER LENS, BIFOCAL $95.50 $86.51 $83.88 V2299 BF - SPECIALITY V2300 TF PL +/-4.00, NO CYLINDER $73.44 $68.64 $61.97 V2301 TF , NO CYLINDER $96.17 $73.06 $73.06 V2302 TF , NO CYLINDER $96.63 $77.88 $77.88 V2303 TF PL +/-4.00, W/CYL PL $69.79 $65.35 $60.99 V2304 TF PL +/-4.00, W/CYL $68.14 $70.06 $63.92 V2305 TF PL +/-4.00, W/CYL $84.62 $78.30 $73.94 V2306 TF PL +/-4.00, W/CYL >6.00 $ $88.07 $76.13 V2307 TF , W/CYL PL $76.29 $74.61 $72.08 V2308 TF , W/CYL $79.38 $77.70 $75.54 V2309 TF , W/CYL $88.78 $82.30 $82.30 V2310 TF , W/CYL >6.00 $81.32 $81.32 $81.32 V2311 TF , W/CYL PL $ $84.61 $84.61 V2312 TF , W/CYL $96.14 $85.10 $85.10 V2313 TF , W/CYL $ $95.04 $95.04 V2314 TF 12.25> ANY CYLINDER $ $ $ V2315 TF LENTICULAR (MYODISC) $ $ $ V2318 TF ANISEIKONIC LENS $ $ $ V2319 TF SEG OVER 28mm $53.23 $47.16 $47.16 V2320 TF ADD OVER 3.25d $66.34 $49.75 $66.34 V2321 LENTICULAR LENS, PER LENS, TRIFOCAL $ $ $ V2399 TF SPECIALITY V2410 SV VARIABLE SPHERE $ $ $85.16 V2430 BF VARIABLE SPHERE $ $ $ V2499 OTHER TYPE V2500 CL - PMMA, SPHERICAL $96.49 $81.66 $79.96 V2501 CL - PMMA, TORIC /PRISM $ $ $ V2502 CL - PMMA, BIFOCAL $ $ $ V2503 CL - PMMA, COLOR DEFICIENCY $ $ $ V2510 CL - GAS PERM, SPHERICAL $ $ $ V2511 CL - GAS PERM, TORIC, PRISM $ $ $ V2512 CL - GAS PERM, BIFOCAL $ $ $ V2513 CL - EXTENDED WEAR $ $ $ V2520 CL - HYDROPHILIC $ $99.04 $ V2521 CL - HYDRO, TORIC $ $ $ V2522 CL - HYDRO, BIFOCAL $ $ $ V2523 CL - HYDRO, EXTENDED WEAR $ $ $ V2530 CL - SCLERAL (GAS IMPERMEABLE) $ $ $ V2531 CL - SCLERAL (GAS PERMEABLE) $ $ $ V2599 CL - OTHER TYPE V2700 BALANCE LENS $50.32 $49.07 $44.16 V2702 DELUXE LENS FEATURES (INCLUDES LENS EDGE TREATMENTS AND LENS DRILLING) V2710 SLAB OFF PRISM $75.54 $73.43 $71.88 V2715 PRISM $12.46 $11.04 $12.64 V2718 PRESS-ON LENS $30.97 $27.11 $27.11 V2730 SPECIAL BASE CURVE $26.70 $20.03 $20.03 V2744 ** TINT - PHOTOCHROMATIC - KX IF MEDICAL NECESSITY DOCUMENTED OR GA (ABN signed) OR GZ (No ABN signed) $19.83 $15.58 $15.58 V2745 ** TINT, ADD-ON, ANY COLOR, SOLID, GRADIENT, OR EQUAL, EACH - KX DOCUMENT OR GA(ABN signed) OR GZ (No ABN) $13.00 $9.98 $10.53 V2750 ** ANTI-REFLECTIVE COATING -KX IF MEDICAL NECESSITY DOCUMENTED OR GA (ABN signed) OR GZ (No ABN signed) $24.17 $18.13 $19.51 V2755 U-V LENS (NOW CONSIDERED ALWAYS MEDICALLY NECESSARY) $21.03 $16.66 $15.77 V2756 EYE GLASS CASE