LAC 40:I.3119. Maximum Allowable Reimbursement

A. Maximum allowable reimbursement lists the maximum payment allowed for vision items described by HCPCS codes. Payment will be the least of: 1. the provider's usual and customary fee; 2. a pre-negotiated amount between the provider and carrier/self-insured employer; or 3. the amount indicated in the maximum allowable reimbursement schedule. 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. V2615 | Telescopic and Other Compound Lens 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.