| Code | Description | Old Price | Allowable | |
| 0191T | I – Stent | $2,700.00 | $2,447.49 | |
| 0192T | Express Shunt | $1,606.76 | $1,594.30 | |
| 65091 | EVISCERATION OCULAR CONTENTS W/O IMPLANT | $1,532.00 | $1,242.07 | |
| 65093 | EVISCERATION OCULAR CONTENTS W/IMPLANT | $1,676.00 | $1,242.07 | |
| 65101 | ENUCLEATION OF EYE W/O IMPLANT | $1,676.00 | $1,242.07 | |
| 65103 | ENUCLEATION EYE IMPLT MUSC X ATTACHED IMPLT | $1,676.00 | $1,242.07 | |
| 65105 | ENUCLEATION EYE IMPLT MUSC ATTACHED IMPLT | $1,676.00 | $1,242.07 | |
| 65110 | EXENTERATION ORBIT REMVL ORBITAL CONTENTS ONLY | $1,676.00 | $1,242.07 | |
| 65112 | EXENTERATION ORBIT RMVL ORBIT CONTENTS & BONE | $1,676.00 | $1,242.07 | |
| 65125 | MODIFICAJ OC IMPLT W/PLMT/RPLCMT PEGS SPX | $892.00 | $768.94 | |
| 65140 | INSJ OC IMPLT AFTER ENCL MUSC ATTACHED | $1,480.00 | $1,242.07 | |
| 65150 | REINSERTION OCULAR IMPLT W/WO CONJUNCTIVAL GRAFT | $1,532.00 | $1,242.07 | |
| 65155 | REINSERTION OCULAR IMPLT RNFCMT&/ATTACHMENT MUSC | $1,676.00 | $1,242.07 | |
| 65175 | REMOVAL OCULAR IMPLANT | $1,532.00 | $1,242.07 | |
| 65205 | REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL | $35.00 | ||
| 65210 | RMVL FB XTRNL EYE EMBED SCJNCL/SCLERAL NONPERFOR | $45.00 | ||
| 65222 | RMVL FB XTRNL EYE CORNEAL W/SLIT LAMP | $41.00 | ||
| 65280 | RPR LAC CORNEA&/SCLERA PERFOR X INVG UVEAL TISS | $1,958.00 | $1,685.57 | |
| 65285 | RPR LAC CORN&/SCLRA PERF W/REPOS/RESCJ UVEAL TIS | $1,958.00 | $1,685.57 | |
| 65286 | RPR LAC APPL TISSUE GLUE WOUND CORNEA&/SCLERA | $550.00 | $445.11 | |
| 65400 | EXCISION LESION CORNEA XCP PTERYGIUM | $690.00 | $400.50 | |
| 65426 | EXCISION/TRANSPOSITION PTERYGIUM W/GRAFG | $1,011.00 | $768.94 | |
| 65435 | RMVL CORNEAL EPITHELIUM W/WO CHEMOCAUTERIZATION | $55.00 | $45.88 | |
| 65436 | RMVL CORNEAL EPITHELIUM W/APPL CHELATING AGENT | $240.00 | $202.36 | |
| 65450 | DSTRJ LESION CRYOTHER PHOTO/THERMOCAUTZATION | $300.00 | $132.61 | |
| 65600 | MULTIPLE PUNCTURES ANTERIOR CORNEA | $235.00 | $231.46 | |
| 65710 | KERATOPLASTY ANTERIOR LAMELLAR | $2,039.00 | $1,685.57 | |
| 65730 | KERATOPLASTY PENTRG EXCEPT APHAKIA/PSEUDOPHAKIA | $1,900.00 | $1,685.57 | |
| 65750 | KERATOPLASTY PENETRAING APHAKIA | $1,900.00 | $1,685.57 | |
| 65755 | KERATOPLASTY PENETRATING PSEUDOPHAKIA | $1,900.00 | $1,685.57 | |
| 65756 | KERATOPLASTY ENDOTHELIAL | $1,900.00 | $1,685.57 | |
| 65772 | CRNL RELAXING INC CORRJ INDUCED ASTIGMATISM | $443.00 | $400.50 | |
| 65775 | CRNL WEDGE RESCJ CORRJ INDUCED ASTIGMATISM | $970.00 | $768.94 | |
| 65780 | OCULAR SURFACE RECONSTRUCTION AMNIOTIC MEMBRANE | $1,600.00 | $1,242.07 | |
| 65800 | PARACENTSIS ANT CHAMB EYE W/DX ASPIR AQUEOUS SPX | $1,065.00 | $943.44 | |
| 65805 | PARACENTSIS ANT CHAM EYE W/THER REL AQUEOUS SPX | $970.00 | ||
| 65815 | PARACEN ANT CHAM RMVL BLOOD W/WO IRRIG&/AIR INJX | $1,101.00 | $943.44 | |
| 65820 | GONIOTOMY | $1,950.00 | $1,685.57 | |
| 65855 | TRABECULOPLASTY LASER SURG 1/> SESSIONS | $300.00 | $129.43 | |
| 65860 | SEVERING ADHESIONS ANTERIOR SEGMENT LASER SPX | $210.00 | $170.51 | |
| 65865 | SEVERING ADS ANT SEG INCAL TQ SPX GONIOSYNECHIAE | $1,101.00 | $943.44 | |
| 65870 | SEVERING ADS ANT SEG INCAL SPX ANT SYNECHIAE | $1,105.00 | $943.44 | |
| 65875 | SEVERING ADS ANT SEG INCAL SPX POST SYNECHIAE | $1,100.00 | $943.44 | |
| 65900 | RMVL EPITHELIAL DOWNGROWTH ANT CHAMBER EYE | $1,101.00 | $943.44 | |
| 65920 | RMVL IMPLANTED MATERIAL ANTERIO SEGMENT EYE | $1,282.00 | $943.44 | |
| 65930 | RMVL BLOOD CLOT ANTERIOR SEGMENT EYE | $1,100.00 | $943.44 | |
| 66020 | INJX ANTERIOR CHAMBER EYE AIR/LIQUID SPX | $1,065.00 | $943.44 | |
| 66030 | INJX ANTERIOR CHAMBER EYE MEDICATION SPX | $1,130.00 | $943.44 | |
| 66170 | FSTLJ SCLERA GLAUCOMA TRABECULECT AB EXTERNO | $1,101.00 | $943.44 | |
| 66172 | FSTLJ SCLERA GLC TRBEC AB EXTERNO SCARRING | $1,101.00 | $943.44 | |
| 66174 | Transluminal Dilation Aqueous | $1,900.00 | $1,685.57 | |
| 66175 | Transluminal Dilation w/Stent | $1,932.00 | $1,685.57 | |
| 66180 | AQUEOUS SHUNT EXTRAOCULAR RESERVOIR | $1,962.00 | $1,685.57 | |
| 66183 | Express Shunt | $1,900.00 | $1,685.57 | |
| 66185 | REVISION AQUEOUS SHUNT EXTRAOCULAR RESERVOIR | $1,101.00 | $943.44 | |
| 66225 | REPAIR SCLERAL STAPHYLOMA W/GRAFT | $1,900.00 | $1,685.57 | |
| 66250 | REVJ/RPR OPRATIVE WOUND ANTERIOR SEGMENT | $1,300.00 | $768.94 | |
| 66625 | IRDEC CRNLSCLRL/CRNL SCTJ PRPH GLC SPX | $1,112.00 | $943.44 | |
| 66680 | REPAIR IRIS CILIARY BODY | $1,112.00 | $943.44 | |
| 66682 | SUTURE IRIS CILIARY BODY SPX RETRIEVAL SUTURE | $1,105.00 | $943.44 | |
| 66711 | CILIARY BODY DSTRJ CYCLOPHOTOCOAG ENDOSCOPIC | $1,077.00 | $943.44 | |
| 66720 | CILIARY BODY DESTRUCTION CRYOTHERAPY | $960.00 | $768.94 | |
| 66761 | IRIDOTOMY/IRRIDECTOMY LASER SURG PER SESSION | $266.00 | $180.10 | |
| 66762 | IRIDOPLASTY PHOTOCOAGULATION 1/> SESSIONS | $266.00 | $241.76 | |
| 66821 | POST-CATARACT LASER SURGERY | $625.00 | $241.76 | |
| 66825 | REPOSITIONING IO LENS PROSTHESIS REQ INC SPX | $1,105.00 | $943.44 | |
| 66830 | RMVL SEC MEMBRANOUS CTRC CORNEO-SCLL SCTJ | $1,101.00 | $943.44 | |
| 66840 | RMVL LENS MATERIAL ASPIR TQ 1/> STAGES | $1,011.00 | $943.44 | |
| 66850 | RMVL LENS MATERIAL PHACOFRAGMENTATION ASPIR | $1,361.00 | $943.44 | |
| 66920 | RMVL LENS MATERIAL INTRACAPSULAR | $1,101.00 | $943.44 | |
| 66940 | REMOVAL LENS MATERIAL EXTRACAPSULAR | $1,270.00 | $943.44 | |
| 66982 | XCAPSULAR CATARACT RMVL INSJ LENS PROSTH 1 STG | $1,270.00 | $943.44 | |
| 66983 | ICAPSULAR CATARACT XTRJ INSJ IO LENS PRSTH 1 STG | $1,270.00 | $943.44 | |
| 66984 | CATARACT REMOVAL INSERTION OF LENS | $1,270.00 | $943.44 | |
| 66985 | INSJ IO LENS PROSTHESIS X W/CONCURRENT RMVL | $1,100.00 | $943.44 | |
| 66986 | EXCHANGE INTRAOCULAR LENS | $1,100.00 | $943.44 | |
| 66999 | Relaxing Incision/SX Induced | $80.00 | ||
| 67005 | RMVL VITREOUS ANT APPR PARTIAL REMOVAL | $989.00 | $943.44 | |
| 67010 | RMVL VITREOUS ANT APPR SUBTOT RMVL MECH VITRECT | $1,011.00 | $943.44 | |
| 67028 | INTRAVITREAL NJX PHARMACOLOGIC AGT SPX | $231.00 | $34.35 | |
| 67028 | INTRAVITREAL NJX PHARMACOLOGIC AGT SPX | $55.00 | $46.22 | |
| 67031 | SEVERING VITREOUS STRANS LASER 1/> STAGES | $500.00 | $241.76 | |
| 67105 | RPR RETINAL DTCHMNT 1/> SES PC W/WO DRG SUBRETIN | $270.00 | $165.03 | |
| 67120 | RMVL IMPLNT MATL POSTERIOR SEGMENT EXTRAOCULAR | $1,083.00 | $943.44 | |
| 67121 | RMVL IMPLT MATRL POSTERIOR SEGMENT INTRAOCULAR | $1,065.00 | $943.44 | |
| 67145 | PROPH RTA DTCHMNT W/O DRG 1/> SESS | $274.00 | $241.76 | |
| 67210 | DSTRJ LOCLZD LES RETINA 1/> SESS PC | $280.00 | $241.76 | |
| 67228 | EXTENSIVE RETINOPATHY 1/> SESS PHOTOCOAGULATION | $280.00 | $172.91 | |
| 67255 | SCLERAL REINFORCEMENT SPX W/GRAFT | $1,105.00 | $943.44 | |
| 67311 | STRABISMUS RECESSION/RESCJ 1 HRZNTL MUSC | $965.00 | $768.94 | |
| 67312 | STRABISMUS RECESSION/RESCJ 2 HRZNTL MUSC | $1,532.00 | $1,242.07 | |
| 67314 | STRABISMUS RECESSION/RESCJ 1 VER MUSC | $905.00 | $768.94 | |
| 67316 | STRABISMUS RECESSION/RESCJ 2/MORE VER MUSC | $1,200.00 | $768.94 | |
| 67320 | TRANSPOSITION PROCEDURE EXTRAOCULAR MUSC | $1,200.00 | ||
| 67331 | STRABISMUS PREVIOUS EYE X INVOLVE EO MUSC | $1,200.00 | ||
| 67335 | PLACEMENT ADJUSTABLE SUTURE STRABISMUS | $995.00 | ||
| 67343 | RLS XTNSV SCAR TISS W/O DETACHING EO MUSC SPX | $900.00 | $768.94 | |
| 67345 | CHEMODENERVATION EXTRAOCULAR MUSCLE | $147.00 | $121.21 | |
| 67400 | ORBITOTOMY W/O BONE FLAP EXPL W/WO BIOPSY | $1,676.00 | $1,242.07 | |
| 67405 | ORBITOTOMY W/O BONE FLAP EXPL W/DRAINAGE ONLY | $922.00 | $768.94 | |
| 67412 | ORBITOTOMY W/O BONE FLAP W/REMOVAL LESION | $892.00 | $768.94 | |
| 67413 | ORBITOTOMY W/O BONE FLAP W/RMVL FOREIGN BODY | $892.00 | $768.94 | |
| 67414 | ORBITOTOMY W/O BONE FLAP W/RMVL BONE DCMPRN | $1,895.00 | $1,242.07 | |
| 67500 | RETROBULBAR INJECTION MEDICATION SPX | $187.00 | $132.61 | |
| 67515 | INJECTION MEDICATION/OTHER SUBST TENON CAPSULE | $54.00 | $43.14 | |
| 67550 | ORBITAL IMPLANT INSERTION | $1,676.00 | $1,242.07 | |
| 67710 | SEVERING TARSORRHAPHY | $218.00 | $179.76 | |
| 67808 | EXC CHALAZION ANES REQ HOSPIZATION SINGLE/MULT | $960.00 | $768.94 | |
| 67820 | CORRECTION TRICHIASIS EPILATION FORCEPS ONLY | $58.00 | $0.00 | |
| 67825 | CORRECTION TRICHIASIS EPILATION OTH/THAN FORCEPS | $324.00 | $72.93 | |
| 67830 | CORRECTION TRICHIASIS INCCISION LID MARGIN | $534.00 | $400.50 | |
| 67835 | CORRJ TRICHIASIS INC LID MRGN W/FR MUC MEMB GRF | $900.00 | $768.94 | |
| 67840 | EXC LESION EYELID W/O CLSR/W/SIMPLE DIR CLOSURE | $250.00 | $192.43 | |
| 67850 | DESTRUCTION LESION LID MRGN < 1 CM | $167.00 | $143.46 | |
| 67875 | TEMPORARY CLOSURE EYELIDS SUTURE | $392.00 | $400.50 | |
| 67880 | CONSTJ INTERMARGIN ADHES/TARSORRH/CANTHORRHAPY | $892.00 | $768.94 | |
| 67882 | CONSTJ INTERMARGIN ADHES/TARSOR/CANTHOR W/TRPOS | $900.00 | $768.94 | |
| 67900 | REPAIR BROW PTOSIS | $1,200.00 | $768.94 | |
| 67901 | RPR BLEPHAROPTOSIS FRONTALIS MUSC SUTR/OTH MATRL | $960.00 | $768.94 | |
| 67902 | RPR BLEPHAROPT FRONTALIS MUSC AUTOL FASCAL SLING | $1,600.00 | $1,242.07 | |
| 67904 | RPR BLEPHAROPTOSIS LEVATOR RESCJ/ADVMNT XTRNL | $866.00 | $768.94 | |
| 67909 | REDUCTION OVERCORRECTION PTOSIS | $960.00 | $768.94 | |
| 67911 | CORRECTION LID RETRACTION | $960.00 | $768.94 | |
| 67912 | CORRJ LAGOPHTHALMOS IMPLTJ UPR EYELID LID LOAD | $960.00 | $768.94 | |
| 67917 | REPAIR ECTROPION EXTENSIVE | $866.00 | $768.94 | |
| 67924 | REPAIR ENTROPION EXTENSIVE | $866.00 | $768.94 | |
| 67930 | SUTR WND EYELID/MARGIN/TARSUS/CONJUNC PRTL THICK | $260.00 | $221.19 | |
| 67935 | SUTR WND EYELID/MARGIN/TARSUS/CONJUNC FULL THICK | $915.00 | $768.94 | |
| 67938 | REMOVAL EMBEDDED FOREIGN BODY EYELID | $187.00 | $132.61 | |
| 67950 | CANTHOPLASTY | $960.00 | $768.94 | |
| 67961 | EXCISION & REPAIR EYELID > ONE-FOURTH LID MARGIN | $960.00 | $768.94 | |
| 67966 | EXCISION & REPAIR EYELID ONE-FOURTH LID MARGIN/> | $960.00 | $768.94 | |
| 67971 | RCNSTJ EYELID FULL THICKNESS < TWO-THIRDS 1 STG | $915.00 | $768.94 | |
| 67973 | RCNSTJ EYELID FULL THICKNESS LOWER EYELID 1 STG | $1,255.00 | $768.94 | |
| 67974 | RCNSTJ EYELID FULL THICKNESS UPPER EYELID 1 STG | $1,532.00 | $1,242.07 | |
| 67975 | RCNSTJ EYELID FULL THICKNESS SECOND STAGE | $950.00 | $768.94 | |
| 68110 | EXCISION LESION CONJUNCTIVA < 1 CM | $180.00 | $154.08 | |
| 68115 | EXCISION LESION CONJUNCTIVA > 1 CM | $890.00 | $768.94 | |
| 68320 | CONJUNCTIVOPLASTY W/GRF/XTNSV REARRANGEMENT | $1,273.00 | $768.94 | |
| 68326 | CJP RCNSTJ CUL-DE-SAC BUCCAL GRF/XTNSV REARRGMT | $1,676.00 | $1,242.07 | |
| 68328 | CONJUNCTPL CUL-DE-SAC W/BUCCAL MUC MEMB GRAFT | $965.00 | $768.94 | |
| 68330 | RPR SYMBLEPHARON CONJUNCTIVOPLASTY W/O GRAFT | $1,077.00 | $943.44 | |
| 68335 | RPR SYMBLEPHARON FR GRF CJNC/BUCCAL MUC MEMB | $1,676.00 | $1,242.07 | |
| 68340 | RPR & DIV SYMBLEPHARON W/WO CONFORM/CONTACT LENS | $866.00 | $768.94 | |
| 68360 | CONJUNCTIVAL FLAP BRIDGE/PARTIAL SPX | $1,550.00 | $1,242.07 | |
| 68440 | SNIP INCISION LACRIMAL PUNCTUM | $76.00 | $63.34 | |
| 68505 | EXCISION LACRIMAL GLAND XCPT TUMOR PRTL | $1,532.00 | $1,242.07 | |
| 68510 | Biopsy of Lacrimal Gland | $900.00 | $768.94 | |
| 68520 | EXCISION LACRIMAL SAC | $1,676.00 | $1,242.07 | |
| 68530 | RMVL FB/DACRYOLITH LACRIMAL PASSAGES | $165.00 | $132.61 | |
| 68700 | PLASTIC REPAIR CANALICULI | $916.00 | $768.94 | |
| 68720 | DACRYOCSTORHINOSTOMY | $1,676.00 | $1,242.07 | |
| 68760 | CLSR LACRIMAL PUNCTUM THERMOCAUT LIG/LASER | $153.00 | $131.82 | |
| 68801 | DILATION LACRIMAL PUNCTUM W/WO IRRGATION | $49.00 | ||
| 68810 | PROBE NASOLACRIMAL DUCT W/WO IRRIGATION | $187.00 | $132.61 | |
| 68811 | PROBE NASOLACRIMAL DUCT W/WO IRRIG REQ GEN ANES | $960.00 | $768.94 | |
| 68815 | PROBE NASOLACRIMAL DUCT W/WO IRRG INSJ TUBE/STNT | $960.00 | $768.94 | |
| J0178 | EYLEA | $1,200.00 | $971.95 | |
| J0585 | Bot Toxin Type A P/unit 100 | $7.00 | $6.13 | |
| J2778 | Lucentis | $660.00 | $386.55 | |
| J3301 | Kenalog 10MG | $4.00 | $1.82 | |
| J3301 | Kenalog 40MG | $384.00 | ||
| J9035 | Avastin | $365.00 | $73.73 | |
| J9190 | Fluorouracil | $6.95 | $2.12 | |
| J9280 | Mitomycin 20 MG Inj | $120.00 | $104.81 | |
| J9291 | Mitomycin 40 MG Inj | $121.00 | ||
| L8610 | Ocular Implant | $700.00 | $619.30 | |
| L8612 | Aqueous Shunt | $775.00 | $653.17 | |
| Q1003 | Tecnis Lens | $150.00 | ||
| Q4116 | AlloDerm, per sq cm | $400.00 | $32.15 | |
| V2785 | Corneal/Scleral Tissue Graft | $4,300.00 | $0.00 |