FORMS & FEES
TREATMENT OF MINOR
CHILDREN 0-15 YEARS
If a parent or guardian is unable to accompany their child to an appointment, then another authorized and responsible adult must accompany them. The parent or guardian must complete and send in a Permission to Accompany a Minor Form with the full name of the responsible party. We will need to see an ID from the accompanying individual. The parent must also agree to be contacted by phone during the exam by the provider or provider's representative. If permission from a parent cannot be obtained, the child cannot be seen.
TREASTMENT OF MINOR
CHILDREN 16-18
Patients between 16-18 years may be seen without a parent. However, the parent or guardian must complete a Permission to Treat a Minor Form. The parent must also agree to be contacted by phone during the exam by the provider or the provider's representative. If permission from a parent cannot be obtained, the child cannot be seen.
FEES
-
99213List Item 1
Level 3 Established Exam: Office visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and a low level of medical decision making.
-
99212List Item 2
Level 2 Established Exam: Office visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.
-
99203List Item 3
Level 3 New Exam: Office visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and a low level of medical decision making.
-
99202List Item 4
Level 2 New Exam: Office visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.
-
92310
CL Services: Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation. Pricing varies depending on level on complexity.
-
92134
OCT Optic Nerve: Scanning computerized ophthalmic diagnostic imaging of the optic nerve, one or both eyes. Includes interpretation and report.
-
92133
OCT Retina: Scanning computerized ophthalmic diagnostic imaging of the retina, one or both eyes. Includes interpretation and report.
-
92083
Diagnostic Visual Fields: Extensive testing of sensitivity of visual field, one or both eyes. Includes interpretation and report.
-
92081
Visual Field Examination, unilateral or bilateral, with interpretation and reportI
-
92015
Refraction and any necessary prescription of lenses.
-
92014
Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, one or more visits.
-
92012
Established Intermediate Exam: Limited evaluation (established patient) of ocular structure and function to detect ocular diseases and determine if further testing is needed.
-
92004
New Comprehensive Exam: Comprehensive evaluation (new patient) of ocular structure and function to detect ocular diseases and determine if further testing is needed.
-
66984
Cataract Surgery
-
66984
Cataract Post-operative Care: Care after cataract surgery in one eye that is coordinated between us and your surgeon. Includes up to 90 days of care after surgery date.
-
66982
Complex Cataract Post-operative Care: Care after a complex cataract surgery in one eye that is coordinated between us and your surgeon. Includes up to 90 days of care after surgery date. (Co-Management)
-
66821
YAG Posterior Capsulotomy Post-operative Care: Care after a YAG laser removal of posterior capsular opacity, coordinated between us and your surgeon. Includes up to 90 days of care after surgery.
-
65222
Corneal Foreign Body Removal: In-office surgical procedure to remove a foreign body that has been identified to be on corneal tissue.
-
65205
Conjunctival Foreign Body Removal: In-office surgical procedure to remove a foreign body that has been identified to be on conjunctival tissue.