2020 UEC FEE SCHEDULE

Examination, Treatment and Procedures

Fee Procedure Code Description (in dollars)

0207T 175 Lipiflow Treatment (per )

Foreign Body Removal, Conjunctival, 65205 100 Superficial

Foreign Body Removal, Conjunctival, 65210 100 Embedded

65222 100 Foreign Body Removal, Corneal, Slit Lamp

Corneal Scraping, Diagnostic, Smear or 65430 500 Culture 65600 650 Stromal Puncture 65778 1,900 Prokera (Amniotic Membrane) 65855 700 By Laser

66761 700 Iridotomy/, By Laser

66821 700 Laser Surgery, Lens (YAG)

66984 55 (modifier Comanagement of Post-Op Portion of 55 for 200 Extracapsular Cataract Removal With comanagement) Insertion of IOL

67028 175 Injection Eye Drug

67105 1250 Retina or Choroid Repair, Photocoagulation

Retina or Choroid Prophylaxis, 67145 1,000 Photocoagulation

Retina or Choroid Destruction, Localized 67210 1,000 Lesion, Photocoagulation Retina or Choroid Destruction, Treatment of 67228 1000 Extensive Retinopathy, Photocoagulation

Injection of Medication or Other Substance 67515 150 Into Tenons Capsule

67800 275 Excision of Chalazion, Single Excision of Chalazion, Multiple, Different 67805 500 Lids

67820 100 Correction of Trichiasis, Epilation, Forceps

Excision of Lesion of (Except 67840 650 Chalzaion) Without Closure or With Simple Direct Closure 68761 250 Closure of Lacrimal Punctum by Plug

Dilation of Lacrimal Punctum, With or 68801 175 Without Irrigation Probing of Lacrimal Canaliculi, With or 68840 175 Without Irrigation

Ophthalmic Ultrasound, Diagnostic, B-scan 76510 250 and Quantitative A-scan Performed During Same Patient Encounter

Ophthalmic Ultrasound, Quantitative A-scan 76511 165 Only

Ophthalmic Ultrasound, B-scan, With or 76512 165 Without Non-quantitative A-scan

Anterior Segment Ultrasound, Immersion B- 76513 150 scan or High Resolution Biomicroscopy

76514 40 Corneal Pachymetry, Unilateral or Bilateral

Ophthalmic Biometry by Ultrasound, A-scan, 76519 130 With IOP Power Calculation Immunoassay for Other Than Infectious 83516 25 Agent (InflammaDry) 83861 35 Tear Osmolarity Testing Psychiatric Diagnostic Evaluation (Intake 90791 400 Interview)

92000 300 Perceptual Evaluation

Ophthalmological Services, Intermediate, 92002 105 New Patient Ophthalmological Services, Comprehensive, 92004 175 New Patient

Ophthalmological Services, Intermediate, 92012 105 Established Patient

Ophthalmological Services, Comprehensive, 92014 150 Established Patient

92015 50 Determination of Refractive State

92015-22 150 Determination of Refractive State - Complex

92020 50 92025 80 Computerized Corneal Topography

92060 90 Sensorimotor Examination 92065 85 Orthoptic Training Fitting of for Treatment of 92071 175 Ocular Service Disease (bandage contact lens)

Fitting of Contact Lens for Management of 92072 600 , Initial, Bilateral

92081 65 Visual Field Examination, Limited

92082 80 Visual Field Examination, Intermediate

92083 105 Visual Field Examination, Extended

92100 125 Serial Tonometry

Scanning Computerized Ophthalmic 92132 75 Diagnostic Imaging, Anterior Segment Scanning Computerized Ophthalmic 92133 75 Diagnostic Imaging, Posterior Segment, Optic Nerve

Scanning Computerized Ophthalmic 92134 75 Diagnostic Imaging, Posterior Segment, Retina

Ophthalmic Biometry by Partial Coherence 92136 135 Interferometry With IOL Power Calculation

Corneal Hysteresis Determination, By Air 92145 30 Impulse Stimulation 92201 40 , Retinal Drawing Ophthalmoscopy, Drawing of Optic Nerve of 92202 35 Macula 92235 175

92250 125 92270 130 Electro-oculography 92273 230 - Full Field

92274 150 Electroretinography - Multifocal

(0509T) 150 Electroretinography - Pattern

92283 150 Color Vision Eximination, Extended

92285 80 External Ocular Photography Anterior Segment Imaging, With Specular 92286 75 Microscopy Degenerative Myopia Intial Fit (fee 92310-52 300 bilateral)

Prescription of Optical and Physical Characteristics of and Fitting of Contact 92310 600 Lens, Medically Necessary, Both (except aphakia)

Fitting of Medically Necessary Contact Lens, 92311 375 Aphakia, 1 Eye Fitting of Medically Necessary Contact Lens, 92312 500 Aphakia, Aphakia, Both Eyes

Fitting of Medically Necessary Contact Lens, 92313 300 Corneoscleral Lens, 1 Eye 95930 190 Visually Evoked Potential (VEP)

Neuropsychological Testing Evaluation Services by Physician or Other Qualified Health Care Professional, Including Integration of Patient Data, Interpretation of Standardized Test Results and Clinical 96132 250 Data, Clinical Decision Making, Treatment Planning and Report, and Interactive Feedback to the Patient, Family Member(s) or Caregiver(s), When Performed, First Hour

Neuropsychological Testing Evaluation 96133 175 Services, Each Additional Hour (Add on Code)

Medical Testimony *Initial, 500* 99075 Up to Two Hours **Each Additional 250** Hour

99201 65 Office Visit, New Patient 99202 95 Office Visit, New Patient 99203 135 Office Visit, New Patient 99204 195 Office Visit, New Patient 99205 245 Office Visit, New Patient 99211 40 Office Visit, Established Patient

99212 60 Office Visit, Established Patient

99213 95 Office Visit, Established Patient 99214 135 Office Visit, Established Patient 99215 170 Office Visit, Established Patient Office Consultation , New or Established 99241 80 Patient Office Consultation , New or Established 99242 125 Patient Office Consultation , New or Established 99243 160 Patient Office Consultation , New or Established 99244 215 Patient Office Consultation , New or Established 99245 280 Patient 99341 85 Home Visit, New Patient 99342 110 Home Visit, New Patient 99343 160 Home Visit, New Patient 99347 50 Home Visit, Established Patient

99348 110 Home Visit, Established Patient

99349 160 Home Visit, Established Patient TT01 795 TrueTear Device TT02 55 TrueTear Tips (package) J9035 100 Bevacizumab injection

Contact Lens Services and Materials Fee Procedure Code Description (in dollars) Starting at 120 V2513 Contact Lens, Rigid Gas Permeable per lens Starting at 40 V2521 Soft Lenses: Toric per box Starting at 45 V2522 Soft Lenses: Multifocal per box

Starting at 35 V2523 Soft Lenses: Spherical per box

Starting at V2599 Rigid Gas Permeable, Keratoconic/Hybrid $250 per lens Starting at V2599 Contact Lens, Orthokeratology $275 per lens

Starting at 425 V2531 Scleral Lens per lens

V2623 2,200 Prosthetic Eye, Plastic, Custom, Per Eye

V2624 100 Polishing/Resurfacing

V2625 500 Enlargement Of Ocular Prosthesis

V2626 500 Reduction/Ocular Prosthesis

V2627 2000 Sclera Cover Shell

Cosmetic Rigid Gas Permeable Contact CL12 600 Lens Professional Fee: Scleral/Hybrid

CL14 400 Orthokeratology- Refit Not Including Lenses

Intermediate Contact Lens/Eye Health CL15 50 Assessment- Elective Wearer

CL20 275 Myopia Control Soft Multifocal CL Fit Myopia Control Orthokeratology CL Fit Not CL21 1,300 Including Lenses CL Assessment with Annual Myopia Control CL22 50 Visit

CL23 175 Myopia Control Soft Multifocal CL Refit Myopia Control Orthokeratology CL Refit CL24 400 Not Including Lenses Annual Soft Contact Lens Evaluation CL101 50 During Comprehensive Examination Annual GP Contact Lens Evaluation During CL102 75 Comprehensive Examination Cosmetic Contact Lens Professional Fee: Soft Refit Existing Wearer Same Lens Design in Toric or Multifocal /Rigid Gas CL103 125 Permeable Refit, Change in Power Only Cosmetic Soft Contact Lens Professional CL104 125 Fee: Standard Fit Cosmetic Soft Contact Lens Professional CL105 175 Fee: Premium Fit

Cosmetic Rigid Gas Permeable Contact CL106 200 Lens Professional Fee Orthokeratology - Initial Fit Not Including CL108 1,300 Lenses

Vision Rehabilitation Materials Fee Description (in dollars) 65 Vision Skills Kit 75 Strabismus Kit ED101 450 Educational/Achievment Testing

Optical Materials Fee Code Description (in dollars) V2020 start at 65 Frames

V2100 65 per pair SV, sph, plano to +/-4.00

SV, spherocyl, plano to +/-4.00 up to 2.00 D V2103 65 per pair cyl V2200 95 per pair Bifocal, sph, plano to +/-4.00

Bifocal, spherocyl, plano to +/-4.00 up to V2203 95 per pair 2.00D cyl 30 additional V2219 Seg over 28mm per pair

30 additional V2220 Bifocal add +3.25 to +4.00 per pair

V2300 160 per pair Trifocal, sph, plano to +/-4.00

Trifocal, spherocyl, plano to +/-4.00 up to V2303 160 per pair 2.00 cyl

30 additional V2319 Trifocal seg over 28mm per pair

30 additional V2320 Trifocal add over +3.25 to +4.00 per pair V2715 3 Prism per diopter per eye V2744 110 per pair Tint, plastic photochromatic V2745 25 per pair Tint, anything except photochromatic

Range from 80 V2750 A/R coating to 175 per pair

V2755 25 per pair U-V coating

V2760 25 per pair S-R coating

V2762 150 per pair Polarization

Starting at 160 additional per V2781 Progressive pair over fee for bifocals Starting at 80 additional per V2783 pair over fee High Index for standard lenses V2784 50 additional Polycarb Kids Packages 99, 149, 189, Rx range = +/- 4.00 Frame and SV polycarbonate lenses 249 with -2.00 cyl Sports Glasses Select Liberty Sports Goggles and SV clear Rx range = +/- 4.00 199 polycarbonate lenses with -2.00 cyl

Telehealth Fee Procedure Code Description (in dollars) 99212 60 Telehealth - Office Visit, Established Patient 99213 95 Telehealth - Office Visit, New Patient 99202 95 Telehealth - Office Visit, New Patient 99441 60 Phone, Eval & Management 5-10 Min 99442 95 Phone, Eval & Management 11-20 Min 99443 135 Phone, Eval & Management 21-30 Min G2012 25 Brief Check in 5-10 MIN G2010 20 Remote Image Review 99453 35 RPM - Training 99454 90 RPM - Loaned Device 99457 90 RPM - Analysis and Discussion

Revised 5/26/2020