Procedure Code Procedure Description Pricing Indicator Rate Type Mod1 Mod2 Mod3 Mod4 Max Fee Max Fee Eff. Date Max Fee End Date PA
65205 REMOVE FOREIGN BODY FROM EYE PRXOVR DEF         NA NA NA N
65205 REMOVE FOREIGN BODY FROM EYE MAXFEE FAC         26.15 1/1/2014 12/31/2299 N
65205 REMOVE FOREIGN BODY FROM EYE MAXFEE NFF         29.42 1/1/2024 12/31/2299 N
65210 REMOVE FOREIGN BODY FROM EYE PRXOVR DEF         NA NA NA N
65210 REMOVE FOREIGN BODY FROM EYE MAXFEE FAC         29.41 1/1/2014 12/31/2299 N
65210 REMOVE FOREIGN BODY FROM EYE MAXFEE NFF         39.45 1/1/2024 12/31/2299 N
65220 REMOVE FOREIGN BODY FROM EYE PRXOVR DEF         NA NA NA N
65220 REMOVE FOREIGN BODY FROM EYE MAXFEE FAC         21.67 1/1/2024 12/31/2299 N
65220 REMOVE FOREIGN BODY FROM EYE MAXFEE NFF         35.46 1/1/2024 12/31/2299 N
65222 REMOVE FOREIGN BODY FROM EYE PRXOVR DEF         NA NA NA N
65222 REMOVE FOREIGN BODY FROM EYE MAXFEE FAC         33.04 1/1/2024 12/31/2299 N
65222 REMOVE FOREIGN BODY FROM EYE MAXFEE NFF         47.59 1/1/2024 12/31/2299 N
65430 CORNEAL SMEAR PRXOVR DEF         NA NA NA N
65430 CORNEAL SMEAR MAXFEE FAC         67.87 1/1/2024 12/31/2299 N
65430 CORNEAL SMEAR MAXFEE NFF         82.03 1/1/2024 12/31/2299 N
67820 REVISE EYELASHES PRXOVR DEF         NA NA NA N
67820 REVISE EYELASHES MAXFEE FAC         22.15 1/1/2024 12/31/2299 N
67820 REVISE EYELASHES MAXFEE NFF         19.38 1/1/2024 12/31/2299 N
67938 REMOVE EYELID FOREIGN BODY PRXOVR DEF         NA NA NA N
67938 REMOVE EYELID FOREIGN BODY MAXFEE FAC         58.83 1/1/2024 12/31/2299 N
67938 REMOVE EYELID FOREIGN BODY MAXFEE NFF         141.89 1/1/2024 12/31/2299 N
68761 CLOSE TEAR DUCT OPENING PRXOVR DEF         NA NA NA N
68761 CLOSE TEAR DUCT OPENING MAXFEE FAC         59.01 1/1/2024 12/31/2299 N
68761 CLOSE TEAR DUCT OPENING MAXFEE NFF         76.99 1/1/2024 12/31/2299 N
68801 DILATE TEAR DUCT OPENING PRXOVR DEF         NA NA NA N
68801 DILATE TEAR DUCT OPENING MAXFEE FAC         48.16 1/1/2024 12/31/2299 N
68801 DILATE TEAR DUCT OPENING MAXFEE NFF         62.34 1/1/2024 12/31/2299 N
68810 PROBE NASOLACRIMAL DUCT PRXOVR DEF         NA NA NA N
68810 PROBE NASOLACRIMAL DUCT MAXFEE FAC         91.21 1/1/2024 12/31/2299 N
68810 PROBE NASOLACRIMAL DUCT MAXFEE NFF         128.96 1/1/2014 12/31/2299 N
68840 EXPLORE/IRRIGATE TEAR DUCTS PRXOVR DEF         NA NA NA N
68840 EXPLORE/IRRIGATE TEAR DUCTS MAXFEE FAC         64.58 1/1/2024 12/31/2299 N
68840 EXPLORE/IRRIGATE TEAR DUCTS MAXFEE NFF         77.43 1/1/2024 12/31/2299 N
76514 ECHO EXAM OF EYE THICKNESS PRXOVR DEF         NA NA NA N
76514 ECHO EXAM OF EYE THICKNESS MAXFEE DEF         8.70 1/1/2024 12/31/2299 N
76514 ECHO EXAM OF EYE THICKNESS MAXFEE DEF TC       2.61 1/1/2024 12/31/2299 N
76514 ECHO EXAM OF EYE THICKNESS MAXFEE DEF 26       6.09 1/1/2024 12/31/2299 N
83861 MICROFLUID ANALY TEARS PRXOVR DEF         NA NA NA N
83861 MICROFLUID ANALY TEARS MAXFEE DEF         16.86 4/1/2019 12/31/2299 N
92002 INTRM OPH EXAM NEW PATIENT PRXOVR DEF         NA NA NA N
92002 INTRM OPH EXAM NEW PATIENT MAXFEE FAC         17.70 1/1/2024 12/31/2299 N
92002 INTRM OPH EXAM NEW PATIENT MAXFEE NFF         31.50 1/1/2024 12/31/2299 N
92004 COMPRE OPH EXAM NEW PT 1/> PRXOVR DEF         NA NA NA S
92004 COMPRE OPH EXAM NEW PT 1/> MAXFEE FAC         36.54 1/1/2024 12/31/2299 S
92004 COMPRE OPH EXAM NEW PT 1/> MAXFEE NFF         56.57 1/1/2024 12/31/2299 S
92012 INTRM OPH EXAM EST PATIENT PRXOVR DEF         NA NA NA N
92012 INTRM OPH EXAM EST PATIENT MAXFEE FAC         19.37 1/1/2024 12/31/2299 N
92012 INTRM OPH EXAM EST PATIENT MAXFEE NFF         39.48 1/1/2024 12/31/2299 N
92014 COMPRE OPH EXAM EST PT 1/> PRXOVR DEF         NA NA NA S
92014 COMPRE OPH EXAM EST PT 1/> MAXFEE FAC         34.73 1/1/2024 12/31/2299 S
92014 COMPRE OPH EXAM EST PT 1/> MAXFEE NFF         57.78 1/1/2024 12/31/2299 S
92015 DETERMINE REFRACTIVE STATE PRXOVR DEF         NA NA NA N
92015 DETERMINE REFRACTIVE STATE MAXFEE FAC         19.73 1/1/2024 12/31/2299 N
92015 DETERMINE REFRACTIVE STATE MAXFEE NFF         20.07 1/1/2024 12/31/2299 N
92020 GONIOSCOPY PRXOVR DEF         NA NA NA N
92020 GONIOSCOPY MAXFEE FAC         11.71 1/1/2024 12/31/2299 N
92020 GONIOSCOPY MAXFEE NFF         13.98 1/1/2024 12/31/2299 N
92025 CPTRIZED CORNEAL TOPOGRAPHY PRXOVR DEF         NA NA NA N
92025 CPTRIZED CORNEAL TOPOGRAPHY MAXFEE DEF         12.51 1/1/2024 12/31/2299 N
92025 CPTRIZED CORNEAL TOPOGRAPHY MAXFEE DEF TC       5 1/1/2024 12/31/2299 N
92025 CPTRIZED CORNEAL TOPOGRAPHY MAXFEE DEF 26       7.51 1/1/2024 12/31/2299 N
92060 SENSORIMOTOR EXAMINATION PRXOVR DEF         NA NA NA N
92060 SENSORIMOTOR EXAMINATION MAXFEE DEF         22.83 1/1/2024 12/31/2299 N
92060 SENSORIMOTOR EXAMINATION MAXFEE DEF TC       6.85 1/1/2024 12/31/2299 N
92060 SENSORIMOTOR EXAMINATION MAXFEE DEF 26       15.98 1/1/2024 12/31/2299 N
92065 ORTHOP TRAING PFRMD PHYS/QHP PRXOVR DEF         NA NA NA Y
92065 ORTHOP TRAING PFRMD PHYS/QHP MAXFEE DEF         15.70 1/1/2024 12/31/2299 Y
92065 ORTHOP TRAING PFRMD PHYS/QHP MAXFEE DEF TC       7.85 1/1/2024 12/31/2299 Y
92065 ORTHOP TRAING PFRMD PHYS/QHP MAXFEE DEF 26       7.85 1/1/2024 12/31/2299 Y
92066 ORTHOP TRAING SUPVJ PHYS/QHP PRXOVR DEF         NA NA NA N
92066 ORTHOP TRAING SUPVJ PHYS/QHP MAXFEE DEF         18.61 1/1/2023 12/31/2299 N
92070 FITTING OF CONTACT LENS PRXOVR DEF         NA NA NA Y
92070 FITTING OF CONTACT LENS MAXFEE DEF         NA     Y
92071 CONTACT LENS FITTING FOR TX PRXOVR DEF         NA NA NA Y
92071 CONTACT LENS FITTING FOR TX MAXFEE FAC         10.32 1/1/2024 12/31/2299 Y
92071 CONTACT LENS FITTING FOR TX MAXFEE NFF         12.70 1/1/2024 12/31/2299 Y
92072 FITG C-LENS KERATOCONUS 1ST PRXOVR DEF         NA NA NA Y
92072 FITG C-LENS KERATOCONUS 1ST MAXFEE FAC         33.43 1/1/2024 12/31/2299 Y
92072 FITG C-LENS KERATOCONUS 1ST MAXFEE NFF         40.61 1/1/2024 12/31/2299 Y
92081 LIMITED VISUAL FIELD XM PRXOVR DEF         NA NA NA N
92081 LIMITED VISUAL FIELD XM MAXFEE DEF         20.73 1/1/2024 12/31/2299 N
92081 LIMITED VISUAL FIELD XM MAXFEE DEF TC       10.36 1/1/2024 12/31/2299 N
92081 LIMITED VISUAL FIELD XM MAXFEE DEF 26       10.37 1/1/2024 12/31/2299 N
92082 INTERMEDIATE VISUAL FIELD XM PRXOVR DEF         NA NA NA N
92082 INTERMEDIATE VISUAL FIELD XM MAXFEE DEF         26.99 1/1/2024 12/31/2299 N
92082 INTERMEDIATE VISUAL FIELD XM MAXFEE DEF TC       13.49 1/1/2024 12/31/2299 N
92082 INTERMEDIATE VISUAL FIELD XM MAXFEE DEF 26       13.50 1/1/2024 12/31/2299 N
92083 EXTENDED VISUAL FIELD XM PRXOVR DEF         NA NA NA N
92083 EXTENDED VISUAL FIELD XM MAXFEE DEF         30.99 1/1/2024 12/31/2299 N
92083 EXTENDED VISUAL FIELD XM MAXFEE DEF TC       15.49 1/1/2024 12/31/2299 N
92083 EXTENDED VISUAL FIELD XM MAXFEE DEF 26       15.50 1/1/2024 12/31/2299 N
92100 SERIAL TONOMETRY PRXOVR DEF         NA NA NA N
92100 SERIAL TONOMETRY MAXFEE FAC         13.31 1/1/2024 12/31/2299 N
92100 SERIAL TONOMETRY MAXFEE NFF         35.36 1/1/2024 12/31/2299 N
92120 TONOGRAPHY & EYE EVALUATION PRXOVR DEF         NA NA NA N
92120 TONOGRAPHY & EYE EVALUATION MAXFEE DEF         NA     N
92130 WATER PROVOCATION TONOGRAPHY PRXOVR DEF         NA NA NA N
92130 WATER PROVOCATION TONOGRAPHY MAXFEE DEF         NA     N
92132 CMPTR OPHTH DX IMG ANT SEGMT PRXOVR DEF         NA NA NA N
92132 CMPTR OPHTH DX IMG ANT SEGMT MAXFEE DEF         14.98 1/1/2024 12/31/2299 N
92132 CMPTR OPHTH DX IMG ANT SEGMT MAXFEE DEF TC       5.99 1/1/2024 12/31/2299 N
92132 CMPTR OPHTH DX IMG ANT SEGMT MAXFEE DEF 26       8.99 1/1/2024 12/31/2299 N
92133 CMPTR OPHTH IMG OPTIC NERVE PRXOVR DEF         NA NA NA N
92133 CMPTR OPHTH IMG OPTIC NERVE MAXFEE DEF         18.35 1/1/2024 12/31/2299 N
92133 CMPTR OPHTH IMG OPTIC NERVE MAXFEE DEF TC       5.51 1/1/2024 12/31/2299 N
92133 CMPTR OPHTH IMG OPTIC NERVE MAXFEE DEF 26       12.85 1/1/2024 12/31/2299 N
92134 CPTR OPHTH DX IMG POST SEGMT PRXOVR DEF         NA NA NA N
92134 CPTR OPHTH DX IMG POST SEGMT MAXFEE DEF         18.35 1/1/2024 12/31/2299 N
92134 CPTR OPHTH DX IMG POST SEGMT MAXFEE DEF TC       5.51 1/1/2024 12/31/2299 N
92134 CPTR OPHTH DX IMG POST SEGMT MAXFEE DEF 26       12.85 1/1/2024 12/31/2299 N
92135 OPHTH DX IMAGING POST SEG PRXOVR DEF         NA NA NA N
92135 OPHTH DX IMAGING POST SEG MAXFEE DEF         NA     N
92136 OPHTHALMIC BIOMETRY PRXOVR DEF         NA NA NA N
92136 OPHTHALMIC BIOMETRY MAXFEE DEF         41.18 1/1/2024 12/31/2299 N
92136 OPHTHALMIC BIOMETRY MAXFEE DEF TC       26.77 1/1/2024 12/31/2299 N
92136 OPHTHALMIC BIOMETRY MAXFEE DEF 26       14.41 1/1/2024 12/31/2299 N
92140 GLAUCOMA PROVOCATIVE TESTS PRXOVR DEF         NA NA NA N
92140 GLAUCOMA PROVOCATIVE TESTS MAXFEE DEF         NA     N
92145 CORNEAL HYSTERESIS DETER PRXOVR DEF         NA NA NA N
92145 CORNEAL HYSTERESIS DETER MAXFEE DEF         13.81 1/1/2024 12/31/2299 N
92145 CORNEAL HYSTERESIS DETER MAXFEE DEF TC       5.52 1/1/2024 12/31/2299 N
92145 CORNEAL HYSTERESIS DETER MAXFEE DEF 26       8.29 1/1/2024 12/31/2299 N
92201 OPSCPY EXTND RTA DRAW UNI/BI PRXOVR DEF         NA NA NA N
92201 OPSCPY EXTND RTA DRAW UNI/BI MAXFEE FAC         20.85 1/1/2024 12/31/2299 N
92201 OPSCPY EXTND RTA DRAW UNI/BI MAXFEE NFF         22.68 1/1/2024 12/31/2299 N
92202 OPSCPY EXTND ON/MAC DRAW PRXOVR DEF         NA NA NA N
92202 OPSCPY EXTND ON/MAC DRAW MAXFEE FAC         13.47 1/1/2024 12/31/2299 N
92202 OPSCPY EXTND ON/MAC DRAW MAXFEE NFF         14.38 1/1/2024 12/31/2299 N
92225 SPECIAL EYE EXAM INITIAL PRXOVR DEF         NA NA NA N
92225 SPECIAL EYE EXAM INITIAL MAXFEE DEF         NA     N
92226 SPECIAL EYE EXAM SUBSEQUENT PRXOVR DEF         NA NA NA N
92226 SPECIAL EYE EXAM SUBSEQUENT MAXFEE DEF         NA     N
92227 IMG RTA DETCJ/MNTR DS STAFF PRXOVR DEF         NA NA NA N
92227 IMG RTA DETCJ/MNTR DS STAFF MAXFEE DEF         5.82 1/1/2024 12/31/2299 N
92228 IMG RTA DETC/MNTR DS PHY/QHP PRXOVR DEF         NA NA NA N
92228 IMG RTA DETC/MNTR DS PHY/QHP MAXFEE DEF         15.21 1/1/2024 12/31/2299 N
92228 IMG RTA DETC/MNTR DS PHY/QHP MAXFEE DEF TC       6.08 1/1/2024 12/31/2299 N
92228 IMG RTA DETC/MNTR DS PHY/QHP MAXFEE DEF 26       9.13 1/1/2024 12/31/2299 N
92229 IMG RTA DETC/MNTR DS POC ALY PRXOVR DEF         NA NA NA N
92229 IMG RTA DETC/MNTR DS POC ALY MAXFEE DEF         0 1/1/2021 12/31/2299 N
92230 FLUORESCEIN ANGIOSCOPY I&R PRXOVR DEF         NA NA NA N
92230 FLUORESCEIN ANGIOSCOPY I&R MAXFEE FAC         15.39 1/1/2024 12/31/2299 N
92230 FLUORESCEIN ANGIOSCOPY I&R MAXFEE NFF         32.90 1/1/2024 12/31/2299 N
92235 FLUORESCEIN ANGRPH MLTIFRAME PRXOVR DEF         NA NA NA N
92235 FLUORESCEIN ANGRPH MLTIFRAME MAXFEE DEF         53.75 1/1/2024 12/31/2299 N
92235 FLUORESCEIN ANGRPH MLTIFRAME MAXFEE DEF TC       34.94 1/1/2024 12/31/2299 N
92235 FLUORESCEIN ANGRPH MLTIFRAME MAXFEE DEF 26       18.81 1/1/2024 12/31/2299 N
92240 ICG ANGIOGRAPHY I&R UNI/BI PRXOVR DEF         NA NA NA N
92240 ICG ANGIOGRAPHY I&R UNI/BI MAXFEE DEF         108.23 1/1/2024 12/31/2299 N
92240 ICG ANGIOGRAPHY I&R UNI/BI MAXFEE DEF TC       86.58 1/1/2024 12/31/2299 N
92240 ICG ANGIOGRAPHY I&R UNI/BI MAXFEE DEF 26       21.65 1/1/2024 12/31/2299 N
92242 FLUORESCEIN&ICG ANGIOGRAPHY PRXOVR DEF         NA NA NA N
92242 FLUORESCEIN&ICG ANGIOGRAPHY MAXFEE DEF         196.64 1/1/2024 12/31/2299 N
92242 FLUORESCEIN&ICG ANGIOGRAPHY MAXFEE DEF TC       147.48 1/1/2024 12/31/2299 N
92242 FLUORESCEIN&ICG ANGIOGRAPHY MAXFEE DEF 26       49.16 1/1/2024 12/31/2299 N
92250 FUNDUS PHOTOGRAPHY W/I&R PRXOVR DEF         NA NA NA N
92250 FUNDUS PHOTOGRAPHY W/I&R MAXFEE DEF         37.66 1/1/2024 12/31/2299 N
92250 FUNDUS PHOTOGRAPHY W/I&R MAXFEE DEF TC       26.36 1/1/2024 12/31/2299 N
92250 FUNDUS PHOTOGRAPHY W/I&R MAXFEE DEF 26       11.30 1/1/2024 12/31/2299 N
92260 OPHTHALMODYNAMOMETRY PRXOVR DEF         NA NA NA N
92260 OPHTHALMODYNAMOMETRY MAXFEE FAC         6.97 1/1/2024 12/31/2299 N
92260 OPHTHALMODYNAMOMETRY MAXFEE NFF         13.17 1/1/2024 12/31/2299 N
92265 NDL OCULOELECTROMYOGRAPHY 1+ PRXOVR DEF         NA NA NA N
92265 NDL OCULOELECTROMYOGRAPHY 1+ MAXFEE DEF         36.04 1/1/2024 12/31/2299 N
92265 NDL OCULOELECTROMYOGRAPHY 1+ MAXFEE DEF TC       18.02 1/1/2024 12/31/2299 N
92265 NDL OCULOELECTROMYOGRAPHY 1+ MAXFEE DEF 26       18.02 1/1/2024 12/31/2299 N
92270 ELECTRO-OCULOGRAPHY W/I&R PRXOVR DEF         NA NA NA N
92270 ELECTRO-OCULOGRAPHY W/I&R MAXFEE DEF         37.98 1/1/2024 12/31/2299 N
92270 ELECTRO-OCULOGRAPHY W/I&R MAXFEE DEF TC       18.99 1/1/2024 12/31/2299 N
92270 ELECTRO-OCULOGRAPHY W/I&R MAXFEE DEF 26       18.99 1/1/2024 12/31/2299 N
92273 FULL FIELD ERG W/I&R PRXOVR DEF         NA NA NA N
92273 FULL FIELD ERG W/I&R MAXFEE DEF         50.57 1/1/2024 12/31/2299 N
92273 FULL FIELD ERG W/I&R MAXFEE DEF TC       35.40 1/1/2024 12/31/2299 N
92273 FULL FIELD ERG W/I&R MAXFEE DEF 26       15.17 1/1/2024 12/31/2299 N
92274 MULTIFOCAL ERG W/I&R PRXOVR DEF         NA NA NA N
92274 MULTIFOCAL ERG W/I&R MAXFEE DEF         35.40 1/1/2024 12/31/2299 N
92274 MULTIFOCAL ERG W/I&R MAXFEE DEF TC       21.24 1/1/2024 12/31/2299 N
92274 MULTIFOCAL ERG W/I&R MAXFEE DEF 26       14.16 1/1/2024 12/31/2299 N
92275 ELECTRORETINOGRAPHY PRXOVR DEF         NA NA NA N
92275 ELECTRORETINOGRAPHY MAXFEE DEF         NA     N
92283 EXTND COLOR VISION XM PRXOVR DEF         NA NA NA N
92283 EXTND COLOR VISION XM MAXFEE DEF         16.92 1/1/2024 12/31/2299 N
92283 EXTND COLOR VISION XM MAXFEE DEF TC       13.54 1/1/2024 12/31/2299 N
92283 EXTND COLOR VISION XM MAXFEE DEF 26       3.38 1/1/2024 12/31/2299 N
92284 DX DARK ADAPTATION EXAM I&R PRXOVR DEF         NA NA NA N
92284 DX DARK ADAPTATION EXAM I&R MAXFEE DEF         32.18 1/1/2024 12/31/2299 N
92284 DX DARK ADAPTATION EXAM I&R MAXFEE DEF TC       25.74 1/1/2024 12/31/2299 N
92284 DX DARK ADAPTATION EXAM I&R MAXFEE DEF 26       6.44 1/1/2024 12/31/2299 N
92285 EXTERNAL OCULAR PHOTOGRAPHY PRXOVR DEF         NA NA NA N
92285 EXTERNAL OCULAR PHOTOGRAPHY MAXFEE DEF         18.38 1/1/2024 12/31/2299 N
92285 EXTERNAL OCULAR PHOTOGRAPHY MAXFEE DEF TC       14.70 1/1/2024 12/31/2299 N
92285 EXTERNAL OCULAR PHOTOGRAPHY MAXFEE DEF 26       3.68 1/1/2024 12/31/2299 N
92286 ANT SGM IMG I&R SPECLR MIC PRXOVR DEF         NA NA NA N
92286 ANT SGM IMG I&R SPECLR MIC MAXFEE DEF         38.25 1/1/2024 12/31/2299 N
92286 ANT SGM IMG I&R SPECLR MIC MAXFEE DEF TC       15.30 1/1/2024 12/31/2299 N
92286 ANT SGM IMG I&R SPECLR MIC MAXFEE DEF 26       22.95 1/1/2024 12/31/2299 N
92287 ANT SGM IMG IR FLRSCN ANGRPH PRXOVR DEF         NA NA NA N
92287 ANT SGM IMG IR FLRSCN ANGRPH MAXFEE DEF         45.28 1/1/2024 12/31/2299 N
92287 ANT SGM IMG IR FLRSCN ANGRPH MAXFEE DEF TC       29.43 1/1/2024 12/31/2299 N
92287 ANT SGM IMG IR FLRSCN ANGRPH MAXFEE DEF 26       15.85 1/1/2024 12/31/2299 N
92310 CONTACT LENS FITTING OU PRXOVR DEF         NA NA NA Y
92310 CONTACT LENS FITTING OU MAXFEE FAC         52.34 1/1/2024 12/31/2299 Y
92310 CONTACT LENS FITTING OU MAXFEE NFF         89.54 1/1/2024 12/31/2299 Y
92311 CONTACT LENS FITG APHAKIA 1 PRXOVR DEF         NA NA NA Y
92311 CONTACT LENS FITG APHAKIA 1 MAXFEE FAC         20.03 1/1/2024 12/31/2299 Y
92311 CONTACT LENS FITG APHAKIA 1 MAXFEE NFF         40.02 1/1/2024 12/31/2299 Y
92312 CONTACT LENS FITG APHAKIA OU PRXOVR DEF         NA NA NA Y
92312 CONTACT LENS FITG APHAKIA OU MAXFEE FAC         23.66 1/1/2024 12/31/2299 Y
92312 CONTACT LENS FITG APHAKIA OU MAXFEE NFF         47.43 1/1/2024 12/31/2299 Y
92313 C-LENS FITG CORNEOSCLRL LENS PRXOVR DEF         NA NA NA Y
92313 C-LENS FITG CORNEOSCLRL LENS MAXFEE FAC         33.94 1/1/2024 12/31/2299 Y
92313 C-LENS FITG CORNEOSCLRL LENS MAXFEE NFF         49.22 1/1/2024 12/31/2299 Y
92314 C-LENS FITG TECH OU PRXOVR DEF         NA NA NA Y
92314 C-LENS FITG TECH OU MAXFEE FAC         25.43 1/1/2024 12/31/2299 Y
92314 C-LENS FITG TECH OU MAXFEE NFF         56.73 1/1/2024 12/31/2299 Y
92315 C-LENS FITG TECH APHAKIA 1 PRXOVR DEF         NA NA NA Y
92315 C-LENS FITG TECH APHAKIA 1 MAXFEE FAC         18.37 1/1/2024 12/31/2299 Y
92315 C-LENS FITG TECH APHAKIA 1 MAXFEE NFF         35.64 1/1/2024 12/31/2299 Y
92316 C-LENS FITG TECH APHAKIA OU PRXOVR DEF         NA NA NA Y
92316 C-LENS FITG TECH APHAKIA OU MAXFEE FAC         27.14 1/1/2024 12/31/2299 Y
92316 C-LENS FITG TECH APHAKIA OU MAXFEE NFF         42.62 1/1/2024 12/31/2299 Y
92317 C-LENS FITG TECH CORNEOSCLRL PRXOVR DEF         NA NA NA Y
92317 C-LENS FITG TECH CORNEOSCLRL MAXFEE FAC         13.29 1/1/2014 12/31/2299 Y
92317 C-LENS FITG TECH CORNEOSCLRL MAXFEE NFF         25.93 1/1/2014 12/31/2299 Y
92325 MODIFICATION OF CONTACT LENS PRXOVR DEF         NA NA NA Y
92325 MODIFICATION OF CONTACT LENS MAXFEE DEF         21.18 1/1/2024 12/31/2299 Y
92326 REPLACEMENT OF CONTACT LENS PRXOVR DEF         NA NA NA Y
92326 REPLACEMENT OF CONTACT LENS MAXFEE DEF         32.76 1/1/2024 12/31/2299 Y
92330 FITTING OF ARTIFICIAL EYE PRXOVR DEF         NA NA NA N
92330 FITTING OF ARTIFICIAL EYE PADOLR DEF         NA NA NA N
92335 FITTING OF ARTIFICIAL EYE PRXOVR DEF         NA NA NA N
92335 FITTING OF ARTIFICIAL EYE PADOLR DEF         NA NA NA N
92340 FIT SPECTACLES MONOFOCAL PRXOVR DEF         NA NA NA S
92340 FIT SPECTACLES MONOFOCAL MAXFEE FAC         11.55 1/1/2024 12/31/2299 S
92340 FIT SPECTACLES MONOFOCAL MAXFEE NFF         25.04 1/1/2024 12/31/2299 S
92341 FIT SPECTACLES BIFOCAL PRXOVR DEF         NA NA NA S
92341 FIT SPECTACLES BIFOCAL MAXFEE FAC         16.05 1/1/2024 12/31/2299 S
92341 FIT SPECTACLES BIFOCAL MAXFEE NFF         31.02 1/1/2024 12/31/2299 S
92342 FIT SPECTACLES MULTIFOCAL PRXOVR DEF         NA NA NA S
92342 FIT SPECTACLES MULTIFOCAL MAXFEE FAC         18.71 1/1/2024 12/31/2299 S
92342 FIT SPECTACLES MULTIFOCAL MAXFEE NFF         34.52 1/1/2024 12/31/2299 S
92352 FIT APHAKIA SPECTCL MONOFOCL PRXOVR DEF         NA NA NA S
92352 FIT APHAKIA SPECTCL MONOFOCL MAXFEE FAC         8.56 1/1/2024 12/31/2299 S
92352 FIT APHAKIA SPECTCL MONOFOCL MAXFEE NFF         22.52 1/1/2024 12/31/2299 S
92353 FIT APHAKIA SPECTCL MULTIFOC PRXOVR DEF         NA NA NA S
92353 FIT APHAKIA SPECTCL MULTIFOC MAXFEE FAC         13.01 1/1/2024 12/31/2299 S
92353 FIT APHAKIA SPECTCL MULTIFOC MAXFEE NFF         29.06 1/1/2024 12/31/2299 S
92354 FITG SPECT LOW VIS 1SYSTEM PRXOVR DEF         NA NA NA Y
92354 FITG SPECT LOW VIS 1SYSTEM MAXFEE DEF         13.56 1/1/2024 12/31/2299 Y
92355 FITG SPECT LW VIS CMPND LENS PRXOVR DEF         NA NA NA Y
92355 FITG SPECT LW VIS CMPND LENS MAXFEE DEF         21.01 1/1/2024 12/31/2299 Y
92358 APHAKIA PROSTH SERVICE TEMP PRXOVR DEF         NA NA NA Y
92358 APHAKIA PROSTH SERVICE TEMP MAXFEE DEF         11.18 1/1/2024 12/31/2299 Y
92390 SUPPLY OF SPECTACLES PRXOVR DEF         NA NA NA Y
92390 SUPPLY OF SPECTACLES PADOLR DEF         NA NA NA Y
92395 SUPPLY OF SPECTACLES PRXOVR DEF         NA NA NA Y
92395 SUPPLY OF SPECTACLES MAXFEE DEF         NA     Y
92499 UNLISTED OPH SVC/PROCEDURE PRXOVR DEF         NA NA NA N
92499 UNLISTED OPH SVC/PROCEDURE MANUAL DEF         NA NA NA N
95919 QUAN PUPLMTRY PHY/QHP UNI/BI PRXOVR DEF         NA NA NA N
95919 QUAN PUPLMTRY PHY/QHP UNI/BI MANUAL DEF         NA NA NA N
99172 OCULAR FUNCTION SCREEN PRXOVR DEF         NA NA NA N
99172 OCULAR FUNCTION SCREEN MAXFEE FAC         8.07 1/1/2018 12/31/2299 N
99172 OCULAR FUNCTION SCREEN MAXFEE NFF         9.94 1/1/2018 12/31/2299 N
99173 VISUAL ACUITY SCREEN PRXOVR DEF         NA NA NA N
99173 VISUAL ACUITY SCREEN MAXFEE DEF         2.40 1/1/2018 12/31/2299 N
99174 OCULAR INSTRUMNT SCREEN BIL PRXOVR DEF         NA NA NA N
99174 OCULAR INSTRUMNT SCREEN BIL MAXFEE FAC         5.88 1/1/2024 12/31/2299 N
99174 OCULAR INSTRUMNT SCREEN BIL MAXFEE NFF         5.88 1/1/2024 12/31/2299 N
99177 OCULAR INSTRUMNT SCREEN BIL PRXOVR DEF         NA NA NA N
99177 OCULAR INSTRUMNT SCREEN BIL MAXFEE FAC         4.84 1/1/2024 12/31/2299 N
99177 OCULAR INSTRUMNT SCREEN BIL MAXFEE NFF         4.84 1/1/2024 12/31/2299 N
99202 OFFICE O/P NEW SF 15 MIN PRXOVR DEF         NA NA NA N
99202 OFFICE O/P NEW SF 15 MIN MAXFEE FAC         24.75 1/1/2024 12/31/2299 N
99202 OFFICE O/P NEW SF 15 MIN MAXFEE NFF         41.27 1/1/2024 12/31/2299 N
99203 OFFICE O/P NEW LOW 30 MIN PRXOVR DEF         NA NA NA N
99203 OFFICE O/P NEW LOW 30 MIN MAXFEE FAC         42.22 1/1/2024 12/31/2299 N
99203 OFFICE O/P NEW LOW 30 MIN MAXFEE NFF         61.22 1/1/2024 12/31/2299 N
99204 OFFICE O/P NEW MOD 45 MIN PRXOVR DEF         NA NA NA N
99204 OFFICE O/P NEW MOD 45 MIN MAXFEE FAC         68.35 1/1/2024 12/31/2299 N
99204 OFFICE O/P NEW MOD 45 MIN MAXFEE NFF         93.36 1/1/2024 12/31/2299 N
99205 OFFICE O/P NEW HI 60 MIN PRXOVR DEF         NA NA NA N
99205 OFFICE O/P NEW HI 60 MIN MAXFEE FAC         92.75 1/1/2024 12/31/2299 N
99205 OFFICE O/P NEW HI 60 MIN MAXFEE NFF         117.31 1/1/2024 12/31/2299 N
99211 OFF/OP EST MAY X REQ PHY/QHP PRXOVR DEF         NA NA NA N
99211 OFF/OP EST MAY X REQ PHY/QHP MAXFEE FAC         5.88 1/1/2024 12/31/2299 N
99211 OFF/OP EST MAY X REQ PHY/QHP MAXFEE NFF         15.37 1/1/2024 12/31/2299 N
99212 OFFICE O/P EST SF 10 MIN PRXOVR DEF         NA NA NA N
99212 OFFICE O/P EST SF 10 MIN MAXFEE FAC         18.34 1/1/2024 12/31/2299 N
99212 OFFICE O/P EST SF 10 MIN MAXFEE NFF         28.73 1/1/2024 12/31/2299 N
99213 OFFICE O/P EST LOW 20 MIN PRXOVR DEF         NA NA NA N
99213 OFFICE O/P EST LOW 20 MIN MAXFEE FAC         33.74 1/1/2024 12/31/2299 N
99213 OFFICE O/P EST LOW 20 MIN MAXFEE NFF         46.23 1/1/2024 12/31/2299 N
99214 OFFICE O/P EST MOD 30 MIN PRXOVR DEF         NA NA NA N
99214 OFFICE O/P EST MOD 30 MIN MAXFEE FAC         49.49 1/1/2024 12/31/2299 N
99214 OFFICE O/P EST MOD 30 MIN MAXFEE NFF         70.11 1/1/2024 12/31/2299 N
99215 OFFICE O/P EST HI 40 MIN PRXOVR DEF         NA NA NA N
99215 OFFICE O/P EST HI 40 MIN MAXFEE FAC         73.54 1/1/2024 12/31/2299 N
99215 OFFICE O/P EST HI 40 MIN MAXFEE NFF         95.01 1/1/2024 12/31/2299 N
99241 OFFICE CONSULTATION PRXOVR DEF         NA NA NA N
99241 OFFICE CONSULTATION MAXFEE DEF         NA     N
99242 OFF/OP CONSLTJ NEW/EST SF 20 PRXOVR DEF         NA NA NA N
99242 OFF/OP CONSLTJ NEW/EST SF 20 MAXFEE FAC         33.92 1/1/2024 12/31/2299 N
99242 OFF/OP CONSLTJ NEW/EST SF 20 MAXFEE NFF         44.13 1/1/2024 12/31/2299 N
99243 OFF/OP CNSLTJ NEW/EST LOW 30 PRXOVR DEF         NA NA NA N
99243 OFF/OP CNSLTJ NEW/EST LOW 30 MAXFEE FAC         47.76 1/1/2024 12/31/2299 N
99243 OFF/OP CNSLTJ NEW/EST LOW 30 MAXFEE NFF         60.74 1/1/2024 12/31/2299 N
99244 OFF/OP CNSLTJ NEW/EST MOD 40 PRXOVR DEF         NA NA NA N
99244 OFF/OP CNSLTJ NEW/EST MOD 40 MAXFEE FAC         76.31 1/1/2024 12/31/2299 N
99244 OFF/OP CNSLTJ NEW/EST MOD 40 MAXFEE NFF         90.50 1/1/2024 12/31/2299 N
99245 OFF/OP CONSLTJ NEW/EST HI 55 PRXOVR DEF         NA NA NA N
99245 OFF/OP CONSLTJ NEW/EST HI 55 MAXFEE FAC         94.48 1/1/2024 12/31/2299 N
99245 OFF/OP CONSLTJ NEW/EST HI 55 MAXFEE NFF         110.40 1/1/2024 12/31/2299 N
99251 INPATIENT CONSULTATION PRXOVR DEF         NA NA NA N
99251 INPATIENT CONSULTATION MAXFEE DEF         NA     N
99252 IP/OBS CONSLTJ NEW/EST SF 35 PRXOVR DEF         NA NA NA N
99252 IP/OBS CONSLTJ NEW/EST SF 35 MAXFEE DEF         39.18 1/1/2024 12/31/2299 N
99253 IP/OBS CNSLTJ NEW/EST LOW 45 PRXOVR DEF         NA NA NA N
99253 IP/OBS CNSLTJ NEW/EST LOW 45 MAXFEE DEF         57.28 1/1/2024 12/31/2299 N
99254 IP/OBS CNSLTJ NEW/EST MOD 60 PRXOVR DEF         NA NA NA N
99254 IP/OBS CNSLTJ NEW/EST MOD 60 MAXFEE DEF         82.54 1/1/2024 12/31/2299 N
99255 IP/OBS CONSLTJ NEW/EST HI 80 PRXOVR DEF         NA NA NA N
99255 IP/OBS CONSLTJ NEW/EST HI 80 MAXFEE DEF         99.84 1/1/2024 12/31/2299 N
99304 1ST NF CARE SF/LOW MDM 25 PRXOVR DEF         NA NA NA N
99304 1ST NF CARE SF/LOW MDM 25 MAXFEE DEF         44.47 1/1/2024 12/31/2299 N
99305 1ST NF CARE MODERATE MDM 35 PRXOVR DEF         NA NA NA N
99305 1ST NF CARE MODERATE MDM 35 MAXFEE DEF         64.20 1/1/2024 12/31/2299 N
99306 1ST NF CARE HIGH MDM 50 PRXOVR DEF         NA NA NA N
99306 1ST NF CARE HIGH MDM 50 MAXFEE DEF         82.37 1/1/2024 12/31/2299 N
99307 SBSQ NF CARE SF MDM 10 PRXOVR DEF         NA NA NA N
99307 SBSQ NF CARE SF MDM 10 MAXFEE DEF         21.80 1/1/2024 12/31/2299 N
99308 SBSQ NF CARE LOW MDM 20 PRXOVR DEF         NA NA NA N
99308 SBSQ NF CARE LOW MDM 20 MAXFEE DEF         34.44 1/1/2024 12/31/2299 N
99309 SBSQ NF CARE MODERATE MDM 30 PRXOVR DEF         NA NA NA N
99309 SBSQ NF CARE MODERATE MDM 30 MAXFEE DEF         45.34 1/1/2024 12/31/2299 N
99310 SBSQ NF CARE HIGH MDM 45 PRXOVR DEF         NA NA NA N
99310 SBSQ NF CARE HIGH MDM 45 MAXFEE DEF         66.79 1/1/2024 12/31/2299 N
99324 DOMICIL/R-HOME VISIT NEW PAT PRXOVR DEF         NA NA NA N
99324 DOMICIL/R-HOME VISIT NEW PAT MAXFEE DEF         NA     N
99325 DOMICIL/R-HOME VISIT NEW PAT PRXOVR DEF         NA NA NA N
99325 DOMICIL/R-HOME VISIT NEW PAT MAXFEE DEF         NA     N
99326 DOMICIL/R-HOME VISIT NEW PAT PRXOVR DEF         NA NA NA N
99326 DOMICIL/R-HOME VISIT NEW PAT MAXFEE DEF         NA     N
99327 DOMICIL/R-HOME VISIT NEW PAT PRXOVR DEF         NA NA NA N
99327 DOMICIL/R-HOME VISIT NEW PAT MAXFEE DEF         NA     N
99328 DOMICIL/R-HOME VISIT NEW PAT PRXOVR DEF         NA NA NA N
99328 DOMICIL/R-HOME VISIT NEW PAT MAXFEE DEF         NA     N
99334 DOMICIL/R-HOME VISIT EST PAT PRXOVR DEF         NA NA NA N
99334 DOMICIL/R-HOME VISIT EST PAT MAXFEE DEF         NA     N
99335 DOMICIL/R-HOME VISIT EST PAT PRXOVR DEF         NA NA NA N
99335 DOMICIL/R-HOME VISIT EST PAT MAXFEE DEF         NA     N
99336 DOMICIL/R-HOME VISIT EST PAT PRXOVR DEF         NA NA NA N
99336 DOMICIL/R-HOME VISIT EST PAT MAXFEE DEF         NA     N
99337 DOMICIL/R-HOME VISIT EST PAT PRXOVR DEF         NA NA NA N
99337 DOMICIL/R-HOME VISIT EST PAT MAXFEE DEF         NA     N
99341 HOME/RES VST NEW SF MDM 15 PRXOVR DEF         NA NA NA N
99341 HOME/RES VST NEW SF MDM 15 MAXFEE DEF         40.36 1/1/2024 12/31/2299 N
99342 HOME/RES VST NEW LOW MDM 30 PRXOVR DEF         NA NA NA N
99342 HOME/RES VST NEW LOW MDM 30 MAXFEE DEF         56.16 1/1/2024 12/31/2299 N
99343 HOME VISIT NEW PATIENT PRXOVR DEF         NA NA NA N
99343 HOME VISIT NEW PATIENT MAXFEE DEF         NA     N
99344 HOME/RES VST NEW MOD MDM 60 PRXOVR DEF         NA NA NA N
99344 HOME/RES VST NEW MOD MDM 60 MAXFEE DEF         104.10 1/1/2024 12/31/2299 N
99345 HOME/RES VST NEW HIGH MDM 75 PRXOVR DEF         NA NA NA N
99345 HOME/RES VST NEW HIGH MDM 75 MAXFEE DEF         125.72 1/1/2024 12/31/2299 N
99347 HOME/RES VST EST SF MDM 20 PRXOVR DEF         NA NA NA N
99347 HOME/RES VST EST SF MDM 20 MAXFEE DEF         31.60 1/1/2024 12/31/2299 N
99348 HOME/RES VST EST LOW MDM 30 PRXOVR DEF         NA NA NA N
99348 HOME/RES VST EST LOW MDM 30 MAXFEE DEF         47.32 1/1/2024 12/31/2299 N
99349 HOME/RES VST EST MOD MDM 40 PRXOVR DEF         NA NA NA N
99349 HOME/RES VST EST MOD MDM 40 MAXFEE DEF         70.13 1/1/2024 12/31/2299 N
99350 HOME/RES VST EST HIGH MDM 60 PRXOVR DEF         NA NA NA N
99350 HOME/RES VST EST HIGH MDM 60 MAXFEE DEF         101.86 1/1/2024 12/31/2299 N
99417 PROLNG OP E/M EACH 15 MIN PRXOVR DEF         NA NA NA N
99417 PROLNG OP E/M EACH 15 MIN MAXFEE FAC         22.87 1/1/2024 12/31/2299 N
99417 PROLNG OP E/M EACH 15 MIN MAXFEE NFF         23.83 1/1/2024 12/31/2299 N
99421 OL DIG E/M SVC 5-10 MIN PRXOVR DEF         NA NA NA N
99421 OL DIG E/M SVC 5-10 MIN MAXFEE FAC         10.41 3/9/2020 12/31/2299 N
99421 OL DIG E/M SVC 5-10 MIN MAXFEE NFF         11.99 3/9/2020 12/31/2299 N
99422 OL DIG E/M SVC 11-20 MIN PRXOVR DEF         NA NA NA N
99422 OL DIG E/M SVC 11-20 MIN MAXFEE FAC         21.38 3/9/2020 12/31/2299 N
99422 OL DIG E/M SVC 11-20 MIN MAXFEE NFF         24.02 3/9/2020 12/31/2299 N
99423 OL DIG E/M SVC 21+ MIN PRXOVR DEF         NA NA NA N
99423 OL DIG E/M SVC 21+ MIN MAXFEE FAC         34.06 3/9/2020 12/31/2299 N
99423 OL DIG E/M SVC 21+ MIN MAXFEE NFF         38.81 3/9/2020 12/31/2299 N
99441 PHONE E/M PHYS/QHP 5-10 MIN PRXOVR DEF         NA NA NA N
99441 PHONE E/M PHYS/QHP 5-10 MIN MAXFEE DEF         0 1/1/2008 12/31/2299 N
99442 PHONE E/M PHYS/QHP 11-20 MIN PRXOVR DEF         NA NA NA N
99442 PHONE E/M PHYS/QHP 11-20 MIN MAXFEE DEF         0 1/1/2008 12/31/2299 N
G2010 REMOT IMAGE SUBMIT BY PT PRXOVR DEF         NA NA NA N
G2010 REMOT IMAGE SUBMIT BY PT MAXFEE FAC         7.30 3/9/2020 12/31/2299 N
G2010 REMOT IMAGE SUBMIT BY PT MAXFEE NFF         9.42 3/9/2020 12/31/2299 N
G2012 BRIEF CHECK IN BY MD/QHP PRXOVR DEF         NA NA NA N
G2012 BRIEF CHECK IN BY MD/QHP MAXFEE FAC         10.41 3/9/2020 12/31/2299 N
G2012 BRIEF CHECK IN BY MD/QHP MAXFEE NFF         11.46 3/9/2020 12/31/2299 N
G2212 PROLONG OUTPT/OFFICE VIS PRXOVR DEF         NA NA NA N
G2212 PROLONG OUTPT/OFFICE VIS MAXFEE FAC         22.66 1/1/2024 12/31/2299 N
G2212 PROLONG OUTPT/OFFICE VIS MAXFEE NFF         23.60 1/1/2024 12/31/2299 N
T1015 CLINIC SERVICE UCCENC UC7         NA NA NA N
T1015 CLINIC SERVICE PRXOVR DEF         NA NA NA N
V2500 CONTACT LENS PMMA SPHERICAL PRXOVR DEF         NA NA NA Y
V2500 CONTACT LENS PMMA SPHERICAL MAXFEE DEF         36.18 1/1/2024 12/31/2299 Y
V2501 CNTCT LENS PMMA-TORIC/PRISM PRXOVR DEF         NA NA NA Y
V2501 CNTCT LENS PMMA-TORIC/PRISM MAXFEE DEF         60.31 1/1/2024 12/31/2299 Y
V2502 CONTACT LENS PMMA BIFOCAL PRXOVR DEF         NA NA NA Y
V2502 CONTACT LENS PMMA BIFOCAL MAXFEE DEF         60.31 1/1/2024 12/31/2299 Y
V2503 CNTCT LENS PMMA COLOR VISION PRXOVR DEF         NA NA NA Y
V2503 CNTCT LENS PMMA COLOR VISION MAXFEE DEF         60.31 1/1/2024 12/31/2299 Y
V2510 CNTCT GAS PERMEABLE SPHERICL PRXOVR DEF         NA NA NA Y
V2510 CNTCT GAS PERMEABLE SPHERICL MAXFEE DEF         58.51 1/1/2024 12/31/2299 Y
V2511 CNTCT TORIC PRISM BALLAST PRXOVR DEF         NA NA NA Y
V2511 CNTCT TORIC PRISM BALLAST MAXFEE DEF         87.75 1/1/2024 12/31/2299 Y
V2512 CNTCT LENS GAS PERMBL BIFOCL PRXOVR DEF         NA NA NA Y
V2512 CNTCT LENS GAS PERMBL BIFOCL MAXFEE DEF         116.99 1/1/2024 12/31/2299 Y
V2513 CONTACT LENS EXTENDED WEAR PRXOVR DEF         NA NA NA Y
V2513 CONTACT LENS EXTENDED WEAR MAXFEE DEF         116.99 1/1/2024 12/31/2299 Y
V2520 CONTACT LENS HYDROPHILIC PRXOVR DEF         NA NA NA Y
V2520 CONTACT LENS HYDROPHILIC MAXFEE DEF         70.20 1/1/2024 12/31/2299 Y
V2521 CNTCT LENS HYDROPHILIC TORIC PRXOVR DEF         NA NA NA Y
V2521 CNTCT LENS HYDROPHILIC TORIC MAXFEE DEF         81.90 1/1/2024 12/31/2299 Y
V2522 CNTCT LENS HYDROPHIL BIFOCL PRXOVR DEF         NA NA NA Y
V2522 CNTCT LENS HYDROPHIL BIFOCL MAXFEE DEF         90.46 1/1/2024 12/31/2299 Y
V2523 CNTCT LENS HYDROPHIL EXTEND PRXOVR DEF         NA NA NA Y
V2523 CNTCT LENS HYDROPHIL EXTEND MAXFEE DEF         113.01 1/1/2024 12/31/2299 Y
V2524 CNTCT LENS HYDROPHIL PHOTOCH PRXOVR DEF         NA NA NA Y
V2524 CNTCT LENS HYDROPHIL PHOTOCH MAXFEE DEF         113.01 1/1/2024 12/31/2299 Y
V2525 CL; HYDROPHILIC; DUAL FOCUS PRXOVR DEF         NA NA NA Y
V2525 CL; HYDROPHILIC; DUAL FOCUS MAXFEE DEF         97 4/1/2022 12/31/2299 Y
V2526 CNTCT LENS BLUE VIOLET PRXOVR DEF         NA NA NA Y
V2526 CNTCT LENS BLUE VIOLET MAXFEE DEF         0 10/1/2023 12/31/2299 Y
V2530 CONTACT LENS GAS IMPERMEABLE PRXOVR DEF         NA NA NA Y
V2530 CONTACT LENS GAS IMPERMEABLE MAXFEE DEF         135.86 1/1/2024 12/31/2299 Y
V2531 CONTACT LENS GAS PERMEABLE PRXOVR DEF         NA NA NA Y
V2531 CONTACT LENS GAS PERMEABLE MAXFEE DEF         494.40 1/1/2024 12/31/2299 Y
V2599 CONTACT LENS/ES OTHER TYPE PRXOVR DEF         NA NA NA Y
V2599 CONTACT LENS/ES OTHER TYPE PADOLR DEF         NA NA NA Y
V2600 HAND HELD LOW VISION AIDS PRXOVR DEF         NA NA NA Y
V2600 HAND HELD LOW VISION AIDS PADOLR DEF         NA NA NA Y
V2610 SINGLE LENS SPECTACLE MOUNT PRXOVR DEF         NA NA NA Y
V2610 SINGLE LENS SPECTACLE MOUNT PADOLR DEF         NA NA NA Y
V2615 TELESCOP/OTHR COMPOUND LENS PRXOVR DEF         NA NA NA Y
V2615 TELESCOP/OTHR COMPOUND LENS PADOLR DEF         NA NA NA Y
V2623 PLASTIC EYE PROSTH CUSTOM PRXOVR DEF         NA NA NA S
V2623 PLASTIC EYE PROSTH CUSTOM MAXFEE DEF         685.77 1/1/2024 12/31/2299 S
V2624 POLISHING ARTIFICAL EYE PRXOVR DEF         NA NA NA S
V2624 POLISHING ARTIFICAL EYE MAXFEE DEF         44.27 1/1/2024 12/31/2299 S
V2625 ENLARGEMNT OF EYE PROSTHESIS PRXOVR DEF         NA NA NA S
V2625 ENLARGEMNT OF EYE PROSTHESIS MAXFEE DEF         350.62 1/1/2024 12/31/2299 S
V2626 REDUCTION OF EYE PROSTHESIS PRXOVR DEF         NA NA NA S
V2626 REDUCTION OF EYE PROSTHESIS MAXFEE DEF         145.09 1/1/2024 12/31/2299 S
V2627 SCLERAL COVER SHELL PRXOVR DEF         NA NA NA S
V2627 SCLERAL COVER SHELL MAXFEE DEF         901.93 1/1/2024 12/31/2299 S
V2628 FABRICATION & FITTING PRXOVR DEF         NA NA NA S
V2628 FABRICATION & FITTING MAXFEE DEF         221.27 1/1/2024 12/31/2299 S
V2629 PROSTHETIC EYE OTHER TYPE PRXOVR DEF         NA NA NA S
V2629 PROSTHETIC EYE OTHER TYPE MANUAL DEF         NA NA NA S
V2799 MISC VISION ITEM OR SERVICE PRXOVR DEF         NA NA NA Y
V2799 MISC VISION ITEM OR SERVICE PADOLR DEF         NA NA NA Y