Schedule F - Provider Cost Claims Data Final.XLSX
XLSX spreadsheet 26 KB Posted
- Attached to
- Vision Insurance Plan Administration for CSC
- Solicitation number
- RFP-171-180000001030-4
- Issued by
- Grand Traverse County, Lansing City, Michigan
About this file
This is a claims data file from a 2018 Michigan Central Services Commission (MCSC) Vision RFP (#180000001030) that contains detailed procedure code listings and claims volume data for FY16 and FY17. The document is structured as a data collection template where bidders are required to enter their network reimbursement rate fee schedules for various vision-related medical procedures, examinations, frames, lenses, and associated services. The template includes yellow-highlighted cells for vendors to input their rates.
The file contains extensive claims volume data across hundreds of vision-related procedure codes, including ophthalmological services, contact lens fittings, frames, various types of lenses (single vision, bifocal, trifocal), and lens enhancements. Notable volume items include frames (32,704 in FY16 and 36,974 in FY17), comprehensive eye exams (20,147 in FY16 and 21,147 in FY17), and progressive lenses (17,719 in FY16 and 21,075 in FY17). Bidders are instructed to use the total claims amounts to determine average claims costs for entry in the pricing matrix (Schedule B) and are asked to provide information about their book of business regarding in-network versus out-of-network provider usage.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| RFP 180000001030 Questions and Answers Final.docx | DOCX document | |
| Schedule J Safeguard Requirements of Confidential Data Final.docx | DOCX document | |
| Schedule A - Final.docx | DOCX document | |
| Schedule C - Plan Design Final.docx | DOCX document | |
| Schedule E - HIPAA 834 File Layouts Final.pdf | ||
| Schedule D - GeoAccess Data Final_Rev 2-28-18.xlsx | XLSX spreadsheet | |
| Standard Contract Terms Final.docx | DOCX document | |
| Vision RPF Q&A #28.xlsx | XLSX spreadsheet | |
| Vision RPF Q&A #33.xlsx | XLSX spreadsheet | |
| Proposal Instructions and Vendor Questions Worksheet Final.docx | DOCX document | |
| Schedule B - Pricing Matrix Final.xlsx | XLSX spreadsheet | |
| Schedule G - Provider Location Data for Disruption Analysis Final_Rev 2-28-18.xlsx | XLSX spreadsheet | |
| Schedule H - Sample Claims Report and Invoice Format Final.xlsx | XLSX spreadsheet | |
| Schedule I - SLA Reporting Format Final.pdf |
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Text version
Document Cover
| 2018 MCSC Vision RFP No. 180000001030 |
| Schedule F - Cost & Claims Data |
Table of Contents
| Tab | |
| 1 | Cost & Claim Data - FY16 |
2 Cost & Claim Data - FY17
Cost & Claims Data - FY16
| 2018 MCSC Vision RFP No. 180000001030 |
| Schedule F - Cost and Claims Data |
FY16
Please enter your network reimbursement rate fee schedule for each procedure code and any applicable notes by populating the yellow highlighted cells below. Use Total Claims Amount below and on additional tab to determine average claims cost for entry in pricing matrix (Schedule B).
Note: Assume that all lens procedure codes are for two-lens prescriptions.
In your Book of Business (BOB), what percent of your members use in-network providers vs. out-of-network providers? Provide response in the box below:
| Procedure Code | Procedure Code Description | Number of Services | Rate per Service | Total Claims Amount Per Code | Notes |
| 92002 | OPHTH SERV: MED EXAM & EVAL; INTERMED NEW PT | 580 | $0.00 | ||
| 92004 | OPHTH SERV: MED EXAM; COMP NEW PT 1/MORE VISITS | 7383 | $0.00 | ||
| 92012 | OPHTH SERV: MED EXAM & EVAL; INITERMED ESTAB PT | 951 | $0.00 | ||
| 92014 | OPHTH SERV: MED EXAM & EVAL; COMP ESTAB PT | 20147 | $0.00 | ||
| 92015 | DETERM REFRACTIVE STATE | 26419 | $0.00 | ||
| 92072 | Fitting CL management keratoconus | 20 | $0.00 | ||
| 92250 | FUNDUS PHOTOGRAPHY W/I&R | 0 | $0.00 | ||
| 92310 | SCRIPT & FIT CONTACT LENS; CORNEAL EX APHAKIA | 1977 | $0.00 | ||
| 92311 | SCRIPT & FIT CONTACT LENS; CORNEAL-APHAKIA-1EYE | 1 | $0.00 | ||
| 92312 | SCRIPT CONTACT LENS; CORNEAL-APHAKIA-BOTH EYES | 11 | $0.00 | ||
| 92313 | SCRIPT & FIT CONTACT LENS; CORNEOSCLERAL LENS | 3 | $0.00 | ||
| 92326 | REPLAC CONTACT LENS | 804 | $0.00 | ||
| 92341 | FITTING SPECTACLES EX APHAKIA; BIFOCAL | 0 | $0.00 | ||
| 92499 | UNLISTED OPHTH SERV/PROC | 7 | $0.00 | ||
| 99202 | OFFIC/OUTPT VISIT E&M NEW LOW-MOD SEVERITY 20MIN | 0 | $0.00 | ||
| 99203 | OFFIC/OUTPT VISIT E&M NEW MODERAT SEVERITY 3OMIN | 12 | $0.00 | ||
| 99204 | OFFIC/OUTPT VISIT E&M NEW MOD-HI SEVERITY 45 MIN | 8 | $0.00 | ||
| 99211 | OFFIC/OUTPT VISIT E&M ESTAB NO PHYS PRES 5 MIN | 0 | $0.00 | ||
| 99212 | OFFIC/OUTPT VISIT E&M EST SELF-LIMIT/MINOR 10MIN | 0 | $0.00 | ||
| 99213 | OFFIC/OUTPT VISIT E&M EST LOW-MOD SEVERITY 15MIN | 12 | $0.00 | ||
| 99214 | OFFIC/OUTPT VISIT E&M EST MOD-HI SEVERITY 25 MIN | 85 | $0.00 | ||
| 99215 | OFFIC/OUTPT VISIT E&M ESTAB MOD-HI SEVRTY 40 MIN | 4 | $0.00 | ||
| S0590 | INTEGRAL LENS SERVICE, MISCELLANEOUS SERVICES REPO | 2 | $0.00 | ||
| S0592 | COMPREHENSIVE CONTACT LENS EVALUATION | 11 | $0.00 | ||
| S0620 | ROUTINE OPHTHALMOLOGICAL EXAMINATION INCLUDING REF | 5542 | $0.00 | ||
| S0621 | ROUTINE OPHTHALMOLOGICAL EXAMINATION INCLUDING REF | 17933 | $0.00 | ||
| V2020 | FRAMES PURCHASES | 32704 | $0.00 | ||
| V2025 | DELUXE FRAME | 1181 | $0.00 | ||
| V2100 | SPHERE 1VIS PLANO +/- 4.00 PER LENS | 4470 | $0.00 | ||
| V2101 | SPHERE 1VIS +/- 4.12-7.00D PER LENS | 325 | $0.00 | ||
| V2102 | SPHERE 1VIS +/- 7.12-20.00D PER LENS | 45 | $0.00 | ||
| V2103 | SPHEROCYLINDER 1VIS PLANO +/-4.0S .12-2.00C EA | 8595 | $0.00 | ||
| V2104 | SPHEROCYLINDER 1VIS PLANO +/-4.0S 2.12-4.0C EA | 652 | $0.00 | ||
| V2105 | SPHEROCYLINDER 1VIS PLANO +/-4.0S 4.25-6.0C EA | 82 | $0.00 | ||
| V2106 | SPHEROCYLINDER 1VIS PLANO +/-4.0S OVER 6.0C EA | 2 | $0.00 | ||
| V2107 | SPHEROCYLINDER 1VIS +/- 4.25-7.00S .12-2.00C EA | 942 | $0.00 | ||
| V2108 | SPHEROCYLINDER 1VIS +/- 4.25-7.00S 2.12-4.00D EA | 128 | $0.00 | ||
| V2109 | SPHEROCYLINDER 1VIS +/- 4.25-7.00S 4.25-6.00D EA | 36 | $0.00 | ||
| V2110 | SPHEROCYLINDER 1VIS +/- 4.25-7.00S 4.25-6.00C EA | 3 | $0.00 | ||
| V2111 | SPHEROCYLINDER 1VIS 4.25-7.00S OVER 6.00C EA | 163 | $0.00 | ||
| V2112 | SPHEROCYLINDER 1VIS +/- 7.25-12.0S .25-2.25C EA | 44 | $0.00 | ||
| V2113 | SPHEROCYLINDER 1VIS +/- 7.25-12.0S 2.25-4.00C EA | 6 | $0.00 | ||
| V2114 | SPHEROCYLINDER 1VIS SPHERE OVER +/- 12.00E EA | 11 | $0.00 | ||
| V2115 | LENTICULAR (MYODISC) PER LENS SINGLE VIS | 1 | $0.00 | ||
| V2121 | LENTICULAR LENS, PER LENS, SINGLE VISION | 1 | $0.00 | ||
| V2199 | NOT OTHERWISE CLASSIFIED SINGLE VIS LENS | 1 | $0.00 | ||
| V2200 | SPHERE BIFOC PLANO TO +/- 4.00D PER LENS | 1252 | $0.00 | ||
| V2201 | SPHERE BIFOC +/- 4.12-7.00D PER LENS | 27 | $0.00 | ||
| V2202 | SPHERE BIFOC +/- 7.12-20.00C PER LENS | 7 | $0.00 | ||
| V2203 | SPHEROCYLINDER BIFOC PLANO +/- 4.0S .12-2.0C EA | 3839 | $0.00 | ||
| V2204 | SPHEROCYLINDER BIFOC PLANO +/-4.0S 2.12=4.0C EA | 408 | $0.00 | ||
| V2205 | SPHEROCYLINDER BIFOC PLANO +/04.0S 4.25-6.0C EA | 29 | $0.00 | ||
| V2206 | SPHEROCYLINDER BIFOC PLANO +/-4.0S OVER 6.0C EA | 2 | $0.00 | ||
| V2207 | SPHEROCYLINDER BIFOC +/-4.25-7.0S .12-2.00C EA | 181 | $0.00 | ||
| V2208 | SPHEROCYLINDER BIFOC +/- 4.25-7.0S 2.12-4.00C EA | 46 | $0.00 | ||
| V2209 | SPHEROCYLINDER BIFOC +/-4.25-7.0S 4.25-6.00C EA | 10 | $0.00 | ||
| V2210 | SPHEROCYLINDER BIFOC +/-4.25-7.0S OVER 6.00C EA | 2 | $0.00 | ||
| V2211 | SPHEROCYLINDER BIFOC +/-7.25-12.0S .25-2.25C EA | 38 | $0.00 | ||
| V2212 | SPHEROCYLINDER BIFOC +/-7.25-12.0S 2.25-4.00C EA | 9 | $0.00 | ||
| V2213 | SPHEROCYLINDER BIFOC +/-7.25-12.0S 4.25-6.00C EA | 2 | $0.00 | ||
| V2214 | SPHEROCYLINDER BIFOC SPHERE OVER +/- 12.00 EA | 3 | $0.00 | ||
| V2220 | BIFOCAL ADD OVER 3.25D | 1 | $0.00 | ||
| V2300 | SPHERE TRIFOC PLANO +/-4.00D PER LENS | 197 | $0.00 | ||
| V2301 | SPHERE TRIFOC +/- 4.12-7.00D PER LENS | 2 | $0.00 | ||
| V2303 | SPHEROCYLINDER TRIFOC PLANO +/-4.0S .12-2.0C EA | 898 | $0.00 | ||
| V2304 | SPHEROCYLINDER TRIFOC PLANO +/-4.0S 2.25-4.0C EA | 133 | $0.00 | ||
| V2305 | SPHEROCYLINDER TRIFOC PLANO +/-4.0S 4.25-6.0C EA | 8 | $0.00 | ||
| V2307 | SPHEROCYLINDER TRIFOC +/-4.25-7.0W .12-2.0C EA | 67 | $0.00 | ||
| V2308 | SPHEROCYLINDER TRIFOC +/-4.25-7.0 S 2.12-4.0C EA | 7 | $0.00 | ||
| V2309 | SPHEROCYLINDER TRIFOC +/-4.25-7.0S 4.25-6.0C EA | 1 | $0.00 | ||
| V2311 | SPHEROCYLINDER TRIFOC +/-7.25-12.0S .25-2.25C EA | 5 | $0.00 | ||
| V2312 | SPHEROCYLINDER TRIFOC +/-7.25-12.0S 2.25-4.0C EA | 2 | $0.00 | ||
| V2410 | VARY ASPHERICITY LENS SINGLE FULL FIELD PER LENS | 1531 | $0.00 | ||
| V2430 | VARY ASPHERICITY BIFOCAL FULL FIELD PER LENS | 21 | $0.00 | ||
| V2499 | VARY SPHERICITY LENS OTHER TYPE | 13 | $0.00 | ||
| V2500 | CONTACT LENS PMMA SPHERICAL PER LENS | 61 | $0.00 | ||
| V2501 | CONTACT LENS PMMA TORIC/PRISM BALLAST PER LENS | 5 | $0.00 | ||
| V2502 | CONTACT LENS PMMA BIFOCAL PER LENS | 5 | $0.00 | ||
| V2503 | CONTACT LENS COLOR VISION DEFICIT PER LENS | 0 | $0.00 | ||
| V2510 | CONTACT LENS GAS PERMEABLE SPHERICAL PER LENS | 168 | $0.00 | ||
| V2511 | CONTACT LENS GAS PERMEABLE TORIC/PRISM PER LENS | 22 | $0.00 | ||
| V2512 | CONTACT LENS GAS PERMEABLE BIFOCAL PER LENS | 41 | $0.00 | ||
| V2513 | CONTACT LENS GAS PERMEABLE EXTEND WEAR PER LENS | 24 | $0.00 | ||
| V2520 | CONTACT LENS HYDROPHILIC SPHERICAL PER LENS | 4159 | $0.00 | ||
| V2521 | CONTACT LENS HYDROPHILIC TORIC/PRISM PER LENS | 1380 | $0.00 | ||
| V2522 | CONTACT LENS HYDROPHILIC BIFOCAL PER LENS | 427 | $0.00 | ||
| V2523 | CONTACT LENS HYDROPHILIC EXTENDED WEAR PER LENS | 208 | $0.00 | ||
| V2530 | CNTCT LENS SCLERAL/GAS IMPERMBL LENS (SEE 92325) | 3 | $0.00 | ||
| V2531 | CONTACT LENS, SCLERAL, GAS PERMEABLE, PER LENS | 28 | $0.00 | ||
| V2599 | CONTACT LENS OTHER TYPE | 412 | $0.00 | ||
| V2600 | HAND HELD LOW VISION/NON SPECTACLE MOUNTED AIDS | 6 | $0.00 | ||
| V2610 | SINGLE LENS SPECTACLE MOUNT LOW VISION AID | 2 | $0.00 | ||
| V2615 | TELESCOPIC/OTHER COMPOUND LES SYSTEM | 6 | $0.00 | ||
| V2702 | Deluxe Lens Feature | 14 | $0.00 | ||
| V2715 | Prism Per Lens | 7 | $0.00 | ||
| V2744 | Tint Photochromatic Per Lens | 15998 | $0.00 | ||
| V2745 | Tint, Any Color, Solid, Gradient, Per Lens | 555 | $0.00 | ||
| V2750 | Anti-Reflective Coating Per Lens | 632 | $0.00 | ||
| V2755 | U-V Lens Per Lens | 10 | $0.00 | ||
| V2756 | Eye Glass Case | 0 | $0.00 | ||
| V2760 | Scratch Resistant Coating Per Lens | 31 | $0.00 | ||
| V2761 | Mirror Coating, Per Lens | 2 | $0.00 | ||
| V2762 | Polarization, Any Lens Material, Per Lens | 23 | $0.00 | ||
| V2781 | Progressive Lens, Per Lens | 17719 | $0.00 | ||
| V2782 | Lens,Index 1.54-1.65plast Or1.60-1.79gls,Per Lens | 37 | $0.00 | ||
| V2783 | Lens, Index >= 1.66 Plast Or >= 1.80 Gls, Per Lens | 15 | $0.00 | ||
| V2784 | Lens, Polycarbonate Or Equal, Any Index, Per Lens | 176 | $0.00 | ||
| V2799 | Vision Service Miscellaneous | 37 | $0.00 | ||
| Total Claims Amount: | $0.00 |
Cost & Claim Data - FY17
| 2018 MCSC Vision RFP No. 180000001030 |
| Schedule F - Cost and Claims Data |
FY17
Please enter your network reimbursement rate fee schedule for each procedure code and any applicable notes by populating the yellow highlighted cells below. Use Total Claims Amount below and on additional tab to determine average claims cost for entry in pricing matrix (Schedule B).
Note: Assume that all lens procedure codes are for two-lens prescriptions.
In your Book of Business (BOB), what percent of your members use in-network providers vs. out-of-network providers? Provide your response in box below:
| Procedure Code | Procedure Code Description | Number of Services | Rate Per Service | Total Claims Amount Per Code | Notes |
| 92002 | OPHTH SERV: MED EXAM & EVAL; INTERMED NEW PT | 454 | $0.00 | ||
| 92004 | OPHTH SERV: MED EXAM; COMP NEW PT 1/MORE VISITS | 7595 | $0.00 | ||
| 92012 | OPHTH SERV: MED EXAM & EVAL; INITERMED ESTAB PT | 1048 | $0.00 | ||
| 92014 | OPHTH SERV: MED EXAM & EVAL; COMP ESTAB PT | 21147 | $0.00 | ||
| 92015 | DETERM REFRACTIVE STATE | 27563 | $0.00 | ||
| 92072 | Fitting CL management keratoconus | 28 | $0.00 | ||
| 92083 | VISUAL FIELD EXAM UNILAT/BILAT W/I&R; EXTEN | 1 | $0.00 | ||
| 92310 | SCRIPT & FIT CONTACT LENS; CORNEAL EX APHAKIA | 2111 | $0.00 | ||
| 92311 | SCRIPT & FIT CONTACT LENS; CORNEAL-APHAKIA-1EYE | 3 | $0.00 | ||
| 92312 | SCRIPT CONTACT LENS; CORNEAL-APHAKIA-BOTH EYES | 11 | $0.00 | ||
| 92313 | SCRIPT & FIT CONTACT LENS; CORNEOSCLERAL LENS | 8 | $0.00 | ||
| 92325 | MODIFICAT LENS (SEP PRO) W/MED SUPERVS ADAPTAT | 1 | $0.00 | ||
| 92326 | REPLAC CONTACT LENS | 648 | $0.00 | ||
| 92341 | FITTING SPECTACLES EX APHAKIA; BIFOCAL | 2 | $0.00 | ||
| 92499 | UNLISTED OPHTH SERV/PROC | 5 | $0.00 | ||
| 99201 | OFFIC/OUTPT VISIT E&M NEW SELF LIMIT/MINOR 10MIN | 0 | $0.00 | ||
| 99202 | OFFIC/OUTPT VISIT E&M NEW LOW-MOD SEVERITY 20MIN | 2 | $0.00 | ||
| 99203 | OFFIC/OUTPT VISIT E&M NEW MODERAT SEVERITY 3OMIN | 11 | $0.00 | ||
| 99204 | OFFIC/OUTPT VISIT E&M NEW MOD-HI SEVERITY 45 MIN | 16 | $0.00 | ||
| 99212 | OFFIC/OUTPT VISIT E&M EST SELF-LIMIT/MINOR 10MIN | 1 | $0.00 | ||
| 99213 | OFFIC/OUTPT VISIT E&M EST LOW-MOD SEVERITY 15MIN | 37 | $0.00 | ||
| 99214 | OFFIC/OUTPT VISIT E&M EST MOD-HI SEVERITY 25 MIN | 79 | $0.00 | ||
| 99215 | OFFIC/OUTPT VISIT E&M ESTAB MOD-HI SEVRTY 40 MIN | 0 | $0.00 | ||
| S0500 | DISPOSABLE CONTACT LENS, PER LENS | 1 | $0.00 | ||
| S0590 | INTEGRAL LENS SERVICE, MISCELLANEOUS SERVICES REPO | 0 | $0.00 | ||
| S0592 | COMPREHENSIVE CONTACT LENS EVALUATION | 4 | $0.00 | ||
| S0620 | ROUTINE OPHTHALMOLOGICAL EXAMINATION INCLUDING REF | 5319 | $0.00 | ||
| S0621 | ROUTINE OPHTHALMOLOGICAL EXAMINATION INCLUDING REF | 17304 | $0.00 | ||
| V2020 | FRAMES PURCHASES | 36974 | $0.00 | ||
| V2025 | DELUXE FRAME | 1251 | $0.00 | ||
| V2100 | SPHERE 1VIS PLANO +/- 4.00 PER LENS | 4497 | $0.00 | ||
| V2101 | SPHERE 1VIS +/- 4.12-7.00D PER LENS | 333 | $0.00 | ||
| V2102 | SPHERE 1VIS +/- 7.12-20.00D PER LENS | 48 | $0.00 | ||
| V2103 | SPHEROCYLINDER 1VIS PLANO +/-4.0S .12-2.00C EA | 8592 | $0.00 | ||
| V2104 | SPHEROCYLINDER 1VIS PLANO +/-4.0S 2.12-4.0C EA | 605 | $0.00 | ||
| V2105 | SPHEROCYLINDER 1VIS PLANO +/-4.0S 4.25-6.0C EA | 79 | $0.00 | ||
| V2106 | SPHEROCYLINDER 1VIS PLANO +/-4.0S OVER 6.0C EA | 4 | $0.00 | ||
| V2107 | SPHEROCYLINDER 1VIS +/- 4.25-7.00S .12-2.00C EA | 892 | $0.00 | ||
| V2108 | SPHEROCYLINDER 1VIS +/- 4.25-7.00S 2.12-4.00D EA | 119 | $0.00 | ||
| V2109 | SPHEROCYLINDER 1VIS +/- 4.25-7.00S 4.25-6.00D EA | 18 | $0.00 | ||
| V2110 | SPHEROCYLINDER 1VIS +/- 4.25-7.00S 4.25-6.00C EA | 2 | $0.00 | ||
| V2111 | SPHEROCYLINDER 1VIS 4.25-7.00S OVER 6.00C EA | 169 | $0.00 | ||
| V2112 | SPHEROCYLINDER 1VIS +/- 7.25-12.0S .25-2.25C EA | 36 | $0.00 | ||
| V2113 | SPHEROCYLINDER 1VIS +/- 7.25-12.0S 2.25-4.00C EA | 8 | $0.00 | ||
| V2114 | SPHEROCYLINDER 1VIS SPHERE OVER +/- 12.00E EA | 14 | $0.00 | ||
| V2200 | SPHERE BIFOC PLANO TO +/- 4.00D PER LENS | 1226 | $0.00 | ||
| V2201 | SPHERE BIFOC +/- 4.12-7.00D PER LENS | 27 | $0.00 | ||
| V2202 | SPHERE BIFOC +/- 7.12-20.00C PER LENS | 9 | $0.00 | ||
| V2203 | SPHEROCYLINDER BIFOC PLANO +/- 4.0S .12-2.0C EA | 3416 | $0.00 | ||
| V2204 | SPHEROCYLINDER BIFOC PLANO +/-4.0S 2.12=4.0C EA | 404 | $0.00 | ||
| V2205 | SPHEROCYLINDER BIFOC PLANO +/04.0S 4.25-6.0C EA | 22 | $0.00 | ||
| V2206 | SPHEROCYLINDER BIFOC PLANO +/-4.0S OVER 6.0C EA | 2 | $0.00 | ||
| V2207 | SPHEROCYLINDER BIFOC +/-4.25-7.0S .12-2.00C EA | 207 | $0.00 | ||
| V2208 | SPHEROCYLINDER BIFOC +/- 4.25-7.0S 2.12-4.00C EA | 42 | $0.00 | ||
| V2209 | SPHEROCYLINDER BIFOC +/-4.25-7.0S 4.25-6.00C EA | 6 | $0.00 | ||
| V2210 | SPHEROCYLINDER BIFOC +/-4.25-7.0S OVER 6.00C EA | 2 | $0.00 | ||
| V2211 | SPHEROCYLINDER BIFOC +/-7.25-12.0S .25-2.25C EA | 30 | $0.00 | ||
| V2212 | SPHEROCYLINDER BIFOC +/-7.25-12.0S 2.25-4.00C EA | 6 | $0.00 | ||
| V2213 | SPHEROCYLINDER BIFOC +/-7.25-12.0S 4.25-6.00C EA | 2 | $0.00 | ||
| V2214 | SPHEROCYLINDER BIFOC SPHERE OVER +/- 12.00 EA | 5 | $0.00 | ||
| V2220 | BIFOCAL ADD OVER 3.25D | 2 | $0.00 | ||
| V2221 | LENTICULAR LENS, PER LENS, BIFOCAL VISION | 1 | $0.00 | ||
| V2300 | SPHERE TRIFOC PLANO +/-4.00D PER LENS | 200 | $0.00 | ||
| V2301 | SPHERE TRIFOC +/- 4.12-7.00D PER LENS | 5 | $0.00 | ||
| V2303 | SPHEROCYLINDER TRIFOC PLANO +/-4.0S .12-2.0C EA | 899 | $0.00 | ||
| V2304 | SPHEROCYLINDER TRIFOC PLANO +/-4.0S 2.25-4.0C EA | 125 | $0.00 | ||
| V2305 | SPHEROCYLINDER TRIFOC PLANO +/-4.0S 4.25-6.0C EA | 9 | $0.00 | ||
| V2307 | SPHEROCYLINDER TRIFOC +/-4.25-7.0W .12-2.0C EA | 49 | $0.00 | ||
| V2308 | SPHEROCYLINDER TRIFOC +/-4.25-7.0 S 2.12-4.0C EA | 9 | $0.00 | ||
| V2311 | SPHEROCYLINDER TRIFOC +/-7.25-12.0S .25-2.25C EA | 5 | $0.00 | ||
| V2312 | SPHEROCYLINDER TRIFOC +/-7.25-12.0S 2.25-4.0C EA | 3 | $0.00 | ||
| V2314 | SPHEROCYLINDER TRIFOC SHPERE OVER +/-12.00D EA | 0 | $0.00 | ||
| V2319 | TRIFOCL SEG WIDTH OVER 28 MM | 0 | $0.00 | ||
| V2410 | VARY ASPHERICITY LENS SINGLE FULL FIELD PER LENS | 1716 | $0.00 | ||
| V2430 | VARY ASPHERICITY BIFOCAL FULL FIELD PER LENS | 41 | $0.00 | ||
| V2499 | VARY SPHERICITY LENS OTHER TYPE | 142 | $0.00 | ||
| V2500 | CONTACT LENS PMMA SPHERICAL PER LENS | 86 | $0.00 | ||
| V2501 | CONTACT LENS PMMA TORIC/PRISM BALLAST PER LENS | 10 | $0.00 | ||
| V2502 | CONTACT LENS PMMA BIFOCAL PER LENS | 2 | $0.00 | ||
| V2503 | CONTACT LENS COLOR VISION DEFICIT PER LENS | 2 | $0.00 | ||
| V2510 | CONTACT LENS GAS PERMEABLE SPHERICAL PER LENS | 127 | $0.00 | ||
| V2511 | CONTACT LENS GAS PERMEABLE TORIC/PRISM PER LENS | 16 | $0.00 | ||
| V2512 | CONTACT LENS GAS PERMEABLE BIFOCAL PER LENS | 44 | $0.00 | ||
| V2513 | CONTACT LENS GAS PERMEABLE EXTEND WEAR PER LENS | 21 | $0.00 | ||
| V2520 | CONTACT LENS HYDROPHILIC SPHERICAL PER LENS | 4366 | $0.00 | ||
| V2521 | CONTACT LENS HYDROPHILIC TORIC/PRISM PER LENS | 1423 | $0.00 | ||
| V2522 | CONTACT LENS HYDROPHILIC BIFOCAL PER LENS | 468 | $0.00 | ||
| V2523 | CONTACT LENS HYDROPHILIC EXTENDED WEAR PER LENS | 165 | $0.00 | ||
| V2530 | CNTCT LENS SCLERAL/GAS IMPERMBL LENS (SEE 92325) | 2 | $0.00 | ||
| V2531 | CONTACT LENS, SCLERAL, GAS PERMEABLE, PER LENS | 48 | $0.00 | ||
| V2599 | CONTACT LENS OTHER TYPE | 450 | $0.00 | ||
| V2600 | HAND HELD LOW VISION/NON SPECTACLE MOUNTED AIDS | 4 | $0.00 | ||
| V2615 | TELESCOPIC/OTHER COMPOUND LES SYSTEM | 3 | $0.00 | ||
| V2715 | Prism Per Lens | 2 | $0.00 | ||
| V2744 | Tint Photochromatic Per Lens | 17621 | $0.00 | ||
| V2745 | Tint, Any Color, Solid, Gradient, Per Lens | 39 | $0.00 | ||
| V2750 | Anti-Reflective Coating Per Lens | 26 | $0.00 | ||
| V2755 | U-V Lens Per Lens | 2 | $0.00 | ||
| V2756 | Eye Glass Case | 0 | $0.00 | ||
| V2781 | Progressive Lens, Per Lens | 21075 | $0.00 | ||
| V2782 | Lens,Index 1.54-1.65plast Or1.60-1.79gls,Per Lens | 8 | $0.00 | ||
| V2799 | Vision Service Miscellaneous | 213 | $0.00 | ||
| Total Claims Amount: | $0.00 |
File details come from the government source that posted it. Updated .