La. Admin. Code tit. 40 § I-3119
State of Louisiana Office of Workers' Compensation Schedule of Maximum Allowances for Vision Services and Supplies | ||
HCPCS | Description | Purchase New |
V2020 | Frames; Purchases | $74 |
V2025 | Deluxe Frame | B.R. |
V2100 | Sphere; Single Vision | $50 |
V2101 | Sphere; Single Vision | $58 |
V2102 | Sphere; Single Vision | $60 |
V2103 | Spherocylinder; Single Vision | $38 |
V2104 | Spherocylinder; Single Vision | $54 |
V2105 | Spherocylinder; Single Vision | $57 |
V2106 | Spherocylinder; Single Vision | $59 |
V2107 | Spherocylinder; Single Vision | $65 |
V2108 | Spherocylinder; Single Vision | $59 |
V2109 | Spherocylinder; Single Vision | $59 |
V2110 | Spherocylinder; Single Vision | $61 |
V2111 | Spherocylinder; Single Vision | $63 |
V2112 | Spherocylinder; Single Vision | $86 |
V2113 | Spherocylinder; Single Vision | $78 |
V2114 | Spherocylinder; Single Vision | $100 |
V2115 | Lenticular; (Myodisc); per Lens | $101 |
V2118 | Aniseikonic Lens; Single Vision | $85 |
V2121 | Lenticular lens, per lens, single | $93 |
V2199 | Not Otherwise Classified | B.R. |
V2200 | Sphere; Bifocal | $66 |
V2201 | Sphere; Bifocal | $66 |
V2202 | Sphere; Bifocal | $92 |
V2203 | Spherocylinder; Bifocal | $65 |
V2204 | Spherocylinder; Bifocal | $69 |
V2205 | Spherocylinder; Bifocal | $74 |
V2206 | Spherocylinder; Bifocal | $83 |
V2207 | Spherocylinder; Bifocal | $66 |
V2208 | Spherocylinder; Bifocal | $91 |
V2209 | Spherocylinder; Bifocal | $77 |
V2210 | Spherocylinder; Bifocal | $87 |
V2211 | Spherocylinder; Bifocal | $80 |
V2212 | Spherocylinder; Bifocal | $89 |
V2213 | Spherocylinder; Bifocal | $120 |
V2214 | Spherocylinder; Bifocal | $125 |
2215 | Lenticular (Myodisc); per Lens | $93 |
V2216 | Lenticular; Nonaspheric; per Lens | $91 |
V2217 | Lenticular; Aspheric Lens; Bifocal | $108 |
V2218 | Aniseikonic; per Lens; Bifocal | $105 |
V2219 | Bifocal Seg Width over 28mm | $59 |
V2220 | Bifocal Add over 3.25d | $60 |
V2221 | Lenticular lens, per lens, bifocal | $109 |
V2299 | Specialty Bifocal (by report) | B.R. |
V2300 | Sphere; Trifocal | $81 |
V2301 | Sphere; Trifocal | $104 |
V2302 | Sphere; Trifocal | $101 |
V2303 | Spherocylinder; Trifocal | $76 |
V2304 | Spherocylinder; Trifocal | $82 |
V2305 | Spherocylinder; Trifocal | $116 |
V2306 | Spherocylinder; Trifocal | $124 |
V2307 | Spherocylinder; Trifocal | $91 |
V2308 | Spherocylinder; Trifocal | $92 |
V2309 | Spherocylinder; Trifocal | $94 |
V2310 | Spherocylinder; Trifocal | $98 |
V2311 | Spherocylinder, Trifocal | $109 |
V2312 | Spherocylinder; Trifocal | $101 |
V2313 | Spherocylinder; Trifocal | $105 |
V2314 | Spherocylinder; Trifocal | $111 |
V2315 | Lenticular; (Myodisc); per Lens | $118 |
V2316 | Lenticular Nonaspheric; per Lens | $111 |
V2317 | Lenticular; Aspheric Lens | $138 |
V2318 | Aniseikonic Lens; Trifocal | $156 |
V2319 | Trifocal Seg Width over 28mm | $75 |
V2320 | Trifocal Add over 3.25d | $84 |
V2321 | Lenticular lens, per lens, trifocal | $145 |
V2399 | Specialty Trifocal (by report) | B.R. |
V2410 | Variable Asphericity Lens | $147 |
V2430 | Variable Asphericity Lens; Bifocal | $141 |
V2499 | Variable Sphericity Lens | B.R. |
V2500 | Contact Lens; PMMA; Spherical | $125 |
V2501 | Contact Lens; PMMA; Toric or Prism | $134 |
V2502 | Contact Lens PMMA; Bifocal | $154 |
V2503 | Contact Lens PMMA; Color Vision | $145 |
V2510 | Contact Lens; Gas Permeable | $171 |
V2511 | Contact Lens; Gas Permeable; Toric | $186 |
V2512 | Contact Lens; Gas Permeable | $277 |
V2513 | Contact Lens; Gas Permeable | $252 |
V2520 | Contact Lens Hydrophilic | $128 |
V2521 | Contact Lens Hydrophilic; Toric | $193 |
V2522 | Contact Lens Hydrophillic; Bifocal | $262 |
V2523 | Contact Lens Hydrophilic; Extended | $181 |
V2530 | Contact Lens; Scleral; per Lens | $277 |
V2531 | Contact lens, scleral, gas permeable, per lens | $783 |
V2599 | Contact Lens; Other Type | B.R. |
V2600 | Hand Held Low Vision Aids | B.R. |
V2610 | Single Lens Spectacle Mounted | B.R. |
V2615 | Telescopic and Other Compound Lens | B.R. |
V2623 | Prosthetic Eye; Plastic; Custom | $1,384 |
V2624 | Polishing Artificial Eye | $78 |
V2625 | Enlargement of Ocular Prosthesis | $374 |
V2626 | Reduction of Ocular Prosthesis | $259 |
V2627 | Scleral Cover Shell | $1,412 |
V2628 | Fabrication and Fitting | $367 |
V2629 | Prosthetic Eye; Other Type | B.R. |
V2630 | Anterior Chamber Intraocular Lens | $534 |
V2631 | Iris Supported Intraocular Lens | $534 |
V2632 | Posterior Chamber Intraocular Lens | $453 |
V2700 | Balance Lens; per Lens | $52 |
V2702 | Deluxe lens feature | B.R. |
V2710 | Slab off Prism; Glass or Plastic | $78 |
V2715 | Prism; per Lens | $19 |
V2718 | Press-on Lens; Fresnell Prism | $41 |
V2730 | Special Base Curve | $33 |
V2744 | Tint; Photochromatic; per Lens | $20 |
V2745 | Addition to lens; tint, any color, solid, gradient or equal, excludes photochromatic, any lens material, per lens | $13 |
V2750 | Anti-Reflective Coating; per Lens | $26 |
V2755 | UV Lens; per Lens | $27 |
V2756 | Eye glass case | $6 |
V2760 | Scratch Resistant Coating | $17 |
V2761 | Mirror coating, any type, solid, gradient or equal, any lens material, per lens | B.R. |
V2762 | Polarization, any lens material, per lens | B.R. |
V2770 | Occluder Lens; per Lens | $29 |
V2780 | Oversize Lens; per Lens | $15 |
V2781 | Progressive lens, per lens | B.R. |
V2782 | Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate, per lens | $71 |
V2783 | Lens, index greater than or equal to 1.66 plastic or greater than or equal to 1.80 glass, excludes polycarbonate, per lens | $80 |
V2784 | Lens, polycarbonate or equal, any index, per lens | $52 |
V2785 | Processing; Transp Corneal Tissue | B.R. |
V2786 | Specialty occupational multifocal lens, per lens | B.R. |
V2787 | Astigmatism correcting function of intraocular lens | B.R. |
V2790 | Amniotic membrane for surgical reconstruction, per procedure | B.R. |
V2797 | Vision supply, accessory and/or service component of another hcpcs vision code | B.R. |
V2799 | Vision Service; Miscellaneous | B.R. |
La. Admin. Code tit. 40, § I-3119