Procedure Code	Procedure Description	Pricing Indicator	Rate Type	Mod1	Mod2	Mod3	Mod4	Max Fee	Max Fee Eff. Date	Max Fee End Date	PA
S0580	POLYCARB LENS	UCBILL	UCA					NA	NA	NA	N
S0580	POLYCARB LENS	UCBILL	DEF					NA	NA	NA	N
S0581	NONSTND LENS	UCBILL	DEF					NA	NA	NA	N
V2020	VISION SVCS FRAMES PURCHASES	UCBILL	UC1					NA	NA	NA	N
V2020	VISION SVCS FRAMES PURCHASES	UCBILL	DEF					NA	NA	NA	N
V2100	LENS SPHER SINGLE PLANO 4.00	UCBILL	DEF					NA	NA	NA	N
V2101	SINGLE VISN SPHERE 4.12-7.00	UCBILL	DEF					NA	NA	NA	N
V2102	SINGL VISN SPHERE 7.12-20.00	UCBILL	DEF					NA	NA	NA	N
V2103	SPHEROCYLINDR 4.00D/12-2.00D	UCBILL	DEF					NA	NA	NA	N
V2104	SPHEROCYLINDR 4.00D/2.12-4D	UCBILL	DEF					NA	NA	NA	N
V2105	SPHEROCYLINDER 4.00D/4.25-6D	UCBILL	DEF					NA	NA	NA	N
V2106	SPHEROCYLINDER 4.00D/>6.00D	UCBILL	DEF					NA	NA	NA	N
V2107	SPHEROCYLINDER 4.25D/12-2D	UCBILL	DEF					NA	NA	NA	N
V2108	SPHEROCYLINDER 4.25D/2.12-4D	UCBILL	DEF					NA	NA	NA	N
V2109	SPHEROCYLINDER 4.25D/4.25-6D	UCBILL	DEF					NA	NA	NA	N
V2110	SPHEROCYLINDER 4.25D/OVER 6D	UCBILL	DEF					NA	NA	NA	N
V2111	SPHEROCYLINDR 7.25D/.25-2.25	UCBILL	DEF					NA	NA	NA	N
V2112	SPHEROCYLINDR 7.25D/2.25-4D	UCBILL	DEF					NA	NA	NA	N
V2113	SPHEROCYLINDR 7.25D/4.25-6D	UCBILL	DEF					NA	NA	NA	N
V2114	SPHEROCYLINDER OVER 12.00D	UCBILL	DEF					NA	NA	NA	N
V2115	LENS LENTICULAR BIFOCAL	UCBILL	DEF					NA	NA	NA	N
V2118	LENS ANISEIKONIC SINGLE	UCBILL	DEF					NA	NA	NA	N
V2121	LENTICULAR LENS; SINGLE	UCBILL	DEF					NA	NA	NA	N
V2199	LENS SINGLE VISION NOT OTH C	UCBILL	UC4					NA	NA	NA	N
V2199	LENS SINGLE VISION NOT OTH C	UCBILL	UC2					NA	NA	NA	N
V2199	LENS SINGLE VISION NOT OTH C	UCBILL	UC3					NA	NA	NA	N
V2199	LENS SINGLE VISION NOT OTH C	UCBILL	DEF					NA	NA	NA	N
V2200	LENS SPHER BIFOC PLANO 4.00D	UCBILL	DEF					NA	NA	NA	N
V2201	LENS SPHERE BIFOCAL 4.12-7.0	UCBILL	DEF					NA	NA	NA	N
V2202	LENS SPHERE BIFOCAL 7.12-20.	UCBILL	DEF					NA	NA	NA	N
V2203	LENS SPHCYL BIFOCAL 4.00D/.1	UCBILL	DEF					NA	NA	NA	N
V2204	LENS SPHCY BIFOCAL 4.00D/2.1	UCBILL	DEF					NA	NA	NA	N
V2205	LENS SPHCY BIFOCAL 4.00D/4.2	UCBILL	DEF					NA	NA	NA	N
V2206	LENS SPHCY BIFOCAL 4.00D/OVE	UCBILL	DEF					NA	NA	NA	N
V2207	LENS SPHCY BIFOCAL 4.25-7D/.	UCBILL	DEF					NA	NA	NA	N
V2208	LENS SPHCY BIFOCAL 4.25-7/2.	UCBILL	DEF					NA	NA	NA	N
V2209	LENS SPHCY BIFOCAL 4.25-7/4.	UCBILL	DEF					NA	NA	NA	N
V2210	LENS SPHCY BIFOCAL 4.25-7/OV	UCBILL	DEF					NA	NA	NA	N
V2211	LENS SPHCY BIFO 7.25-12/.25-	UCBILL	DEF					NA	NA	NA	N
V2212	LENS SPHCYL BIFO 7.25-12/2.2	UCBILL	DEF					NA	NA	NA	N
V2213	LENS SPHCYL BIFO 7.25-12/4.2	UCBILL	DEF					NA	NA	NA	N
V2214	LENS SPHCYL BIFOCAL OVER 12.	UCBILL	DEF					NA	NA	NA	N
V2215	LENS LENTICULAR BIFOCAL	UCBILL	DEF					NA	NA	NA	N
V2218	LENS ANISEIKONIC BIFOCAL	UCBILL	DEF					NA	NA	NA	N
V2219	LENS BIFOCAL SEG WIDTH OVER	UCBILL	DEF					NA	NA	NA	N
V2220	LENS BIFOCAL ADD OVER 3.25D	UCBILL	DEF					NA	NA	NA	N
V2221	LENTICULAR LENS; BIFOCAL	UCBILL	DEF					NA	NA	NA	N
V2299	LENS BIFOCAL SPECIALITY	UCBILL	UC4					NA	NA	NA	N
V2299	LENS BIFOCAL SPECIALITY	UCBILL	UC5					NA	NA	NA	N
V2299	LENS BIFOCAL SPECIALITY	UCBILL	UC2					NA	NA	NA	N
V2299	LENS BIFOCAL SPECIALITY	UCBILL	UC3					NA	NA	NA	N
V2299	LENS BIFOCAL SPECIALITY	UCBILL	UC6					NA	NA	NA	N
V2299	LENS BIFOCAL SPECIALITY	UCBILL	DEF					NA	NA	NA	N
V2300	LENS SPHERE TRIFOCAL 4.00D	UCBILL	DEF					NA	NA	NA	N
V2301	LENS SPHERE TRIFOCAL 4.12-7.	UCBILL	DEF					NA	NA	NA	N
V2302	LENS SPHERE TRIFOCAL 7.12-20	UCBILL	DEF					NA	NA	NA	N
V2303	LENS SPHCY TRIFOCAL 4.0/.12-	UCBILL	DEF					NA	NA	NA	N
V2304	LENS SPHCY TRIFOCAL 4.0/2.25	UCBILL	DEF					NA	NA	NA	N
V2305	LENS SPHCY TRIFOCAL 4.0/4.25	UCBILL	DEF					NA	NA	NA	N
V2306	LENS SPHCYL TRIFOCAL 4.00/>6	UCBILL	DEF					NA	NA	NA	N
V2307	LENS SPHCY TRIFOCAL 4.25-7/.	UCBILL	DEF					NA	NA	NA	N
V2308	LENS SPHC TRIFOCAL 4.25-7/2.	UCBILL	DEF					NA	NA	NA	N
V2309	LENS SPHC TRIFOCAL 4.25-7/4.	UCBILL	DEF					NA	NA	NA	N
V2310	LENS SPHC TRIFOCAL 4.25-7/>6	UCBILL	DEF					NA	NA	NA	N
V2311	LENS SPHC TRIFO 7.25-12/.25-	UCBILL	DEF					NA	NA	NA	N
V2312	LENS SPHC TRIFO 7.25-12/2.25	UCBILL	DEF					NA	NA	NA	N
V2313	LENS SPHC TRIFO 7.25-12/4.25	UCBILL	DEF					NA	NA	NA	N
V2314	LENS SPHCYL TRIFOCAL OVER 12	UCBILL	DEF					NA	NA	NA	N
V2315	LENS LENTICULAR TRIFOCAL	UCBILL	DEF					NA	NA	NA	N
V2318	LENS ANISEIKONIC TRIFOCAL	UCBILL	DEF					NA	NA	NA	N
V2319	LENS TRIFOCAL SEG WIDTH > 28	UCBILL	DEF					NA	NA	NA	N
V2320	LENS TRIFOCAL ADD OVER 3.25D	UCBILL	DEF					NA	NA	NA	N
V2321	LENTICULAR LENS; TRIFOCAL	UCBILL	DEF					NA	NA	NA	N
V2410	LENS VARIAB ASPHERICITY SING	UCBILL	DEF					NA	NA	NA	N
V2430	LENS VARIABLE ASPHERICITY BI	UCBILL	DEF					NA	NA	NA	N
V2700	BALANCE LENS	UCBILL	DEF					NA	NA	NA	N
V2710	GLASS/PLASTIC SLAB OFF PRISM	UCBILL	DEF					NA	NA	NA	N
V2715	PRISM LENS/ES	UCBILL	DEF					NA	NA	NA	N
V2718	FRESNELL PRISM PRESS-ON LENS	UCBILL	DEF					NA	NA	NA	N
V2730	SPECIAL BASE CURVE	UCBILL	DEF					NA	NA	NA	N
V2744	TINT PHOTOCHROMATIC LENS/ES	UCBILL	DEF					NA	NA	NA	Y
V2745	TINT; ANY COLOR/SOLID/GRAD	UCBILL	DEF					NA	NA	NA	Y
V2755	UV LENS/ES	UCBILL	DEF					NA	NA	NA	Y
V2760	SCRATCH RESISTANT COATING	UCBILL	DEF					NA	NA	NA	N
V2770	OCCLUDER LENS/ES	UCBILL	DEF					NA	NA	NA	N
V2782	LENS; 1.54-1.65 P/1.60-1.79G	UCBILL	DEF					NA	NA	NA	N
V2783	LENS; >= 1.66 P/>=1.80 G	UCBILL	DEF					NA	NA	NA	N
V2799	MISC VISION ITEM OR SERVICE	PADOLR	DEF					NA	NA	NA	E