Louisiana Administrative Code
Title 40 - LABOR AND EMPLOYMENT
Part I - Workers' Compensation Administration
Subpart 2 - Medical Guidelines
Chapter 31 - Vision Care Services, Reimbursement Schedule, Billing Instruction and Maintenance Procedures
Section I-3119 - Maximum Allowable Reimbursement

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.