PPN PRICE LIST Consultations 2 Grid 3 Lenses & Extras 4 Branded Extras 5 Contact Lenses

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Alyson Adams
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PPN PRICE LIST 2012 1 Consultations 2 Grid 3

1 PPN PRICE LIST Consultations 2 Grid 3 Lenses & Extras 4 Branded Extras 5 Contact Lenses

2 PPN Consultations 2012 OPTOMETRIC EXAMINATIONS PPN DESCRIPTION PRICE Composite Consultation R Consultation Only R Consultation & Tonometry/Visual Fields R Re-Examination R Binocular Instability Evaluation - Simple Case R Contact Lens Re-Examination R Binocular Instability Evaluation - Complex Case R 744 Code 70001: Composite consultation includes Refraction, Tonometry and Visual Field Screening DIAGNOSTIC PROCEDURES These are procedures based on findings arising out of the Optometric Examination. VISUALLY RELATED DISORDERS Visually Related Learning Disorders Evaluation R Eye Movements Evaluation (E.G. Visigraph) R Cycloplegic Refraction R Preferential Looking (Infants < Two Years) R 187 COLORIMETRY CODES Corneal Topography R Reading Rate- screening R Gonioscopy R Reading Ortho-Didactical skills evaluation R Dilated Fundus Examination / BIO R Colorimetry Intuitive - evaluation R Visual Field - Evaluation R Visual Field - Threshold Testing R 311 VISUAL THERAPY/ ORTHOPTICS TRAINING Clolour Vision Evaluation R Vision Training - Home Therapy Instruction R Contrast Sensitivity Evaluation R Vision Training - Individual (per 15 minutes) R Lacrimal System Evaluation R Vision Training - Individual (per 30 minutes) R Photography of Anterior Segment R Vision Training - Group per Patient (per 15 minutes) R Photography of Fundus R Vision Training - Away From Practice (add to or 22011) R Photographic Materials Pachymetry R Retinal Nerve Fibre Layer Analysis (RNFLA) R Visual Evoked Potentials (VEP) - Unilateral Visual Evoked Potentials (VEP) - Bilateral PROCEDURES DONE IN ISOLATION Follow-up procedures or specific requests by patients or medical practitioners. The clinical rule that applies:codes can be used as a professional fee in isolation but may not be charged in conjunction with Optometric Examinations. BINOCULAR VISION/ORTHOPTICS These evaluations are done in addition to an Optometric Examination. Special examination techniques apply to this area of expertise. The differentiating factor regarding Simple and Complex cases is by default: Complex cases have to do with Eccentric Fixation and / or Anomalous Retinal Correspondence. LOW VISION The Low Vision Assessment examination is performed in addition to a visual examination where patients present with visual acuity that is worse than 6/18 or visual fields that are severely restricted. LOW VISION ASSESSMENT& TRAINING (per half hour) Low Vision Assessment per 30 mins R Low Vision Training per 30 mins R 373 SPORTS VISION Refractive Status Evaluation R Ocular Pathology Screening R 187 SPORTS VISION - IN OFFICES PROCEDURES Keratometry R Sports Vision Individual Screening R Tonometry (Non-contact) R Sports Vision Individual Evaluation R Tonometry (Aplanation) R Sports Vision Individual Training (per 15 minutes) R Colour Vision Screening R Sports Vision Group Screening R Visual Field - Screening R Sports Vision Group Evaluation R Sports Vision Group Training (per 15 minutes) R 47 CONTACT LENS PROFESSIONAL FEES & PROCEDURES Code refers to OTC dispensing ; either re-ordered or from other practices SPORTS VISION - PROCEDURES DONE IN THE FIELD C Lens Consultation Basic - per visit R Sports Vision Individual Screening R C Lens Consultation Complex - per visit R Sports Vision Individual Evaluation R C Lens Consultation Advanced - per visit R Sports Vision Individual Training (per 15 minutes) R C Lens follow-up Examination/Basic Case - per visit R Sports Vision Group Screening R C Lens follow-up Examination/Complex Case - per visit R Sports Vision Group Evaluation R C Lens follow-up Examination/Advanced Case - per visit R Sports Vision Group Training (per 15 minutes) R C Lens Related ProblemsAssessment - Monocular R C Lens Related Problems Assessment- Binocular R 187 DISPENSING FEE (per pair) C Lens Instruction R Dispensing Fee - Single Vision R C Lens Dispensing and/or Assessment R Dispensing Fee - Bifocals R Dispensing Fee - Varifocals R 124 OPTOMETRIC SCREENING SERVICES Screening School (per hour) R 744 SERVICES OUTSIDE OF REGULAR OFFICE HOURS Screening Industrial (per hour) R After Hours or Away from Practice Visit R Broken Appointments REPORTS etc Report at request of Medical Aid. R Report at Patient's request (arising from Consultations) R 311 PPN Tariff List PPN2 (Compiled CG )

3 PPN TARIFFS 1 JANUARY 2012 ALL LENS PRICES INCLUDE THE COST OF EXTRA LARGE BLANKS AND PRISM These prices are the maximum amount that PPN will pay out towards the codes set out below CLEAR LENS CLEAR LENS ADD ONS LENS TYPE PPN 1 PPN 2 PGX HARDCOAT VAC COAT<35% VAC COAT>35% AR MULTI AR SUPER FIXED TINT< 35% FIXED TINT>35% SINGLE Vision Glass R 130 R 165 R 167 R 152 R 187 R 248 R 333 R 360 R 392 R 569 LENS TYPE PPN 1 PPN 2 GREYMATIC HARDCOAT UV400 POLARIZED AR MULTI AR SUPER GRADIENT TINT GRADIENT TINT SINGLE Vision Plastic R 130 R 165 R 416 R 160 R 155 R 769 R 151 R 423 R 114 R 114 LENS TYPE PPN 1 PPN 2 PGX HARDCOAT VAC COAT<35% VAC COAT>35% AR MULTI AR SUPER FIXED TINT< 35% FIXED TINT>35% AQUITY Bifocal Glass R 290 R 375 R 208 R 152 R 187 R 248 R 333 R 360 R 392 R 569 LENS TYPE PPN 1 PPN 2 GREYMATIC HARDCOAT UV400 POLARIZED AR MULTI AR SUPER GRADIENT TINT GRADIENT TINT AQUITY Bifocal Plastic R 290 R 375 R 831 R 160 R 155 R 769 R 151 R 423 R 114 R 114 LENS TYPE PPN 1 PPN 2 PGX HARDCOAT VAC COAT<35% VAC COAT>35% AR MULTI AR SUPER FIXED TINT< 35% FIXED TINT>35% AQUITY Multifocal Glass R 530 R 655 R 282 R 152 R 187 R 248 R 333 R 360 R 392 R 569 LENS TYPE PPN 1 PPN 2 GREYMATIC HARDCOAT UV400 POLARIZED AR MULTI AR SUPER GRADIENT TINT GRADIENT TINT AQUITY Multifocal Polymer R 530 R 655 R 831 R 160 R 155 R 769 R 151 R 423 R 114 R 114 PPN TARIFF 1 2 & 3 PPN MAX PRICE TRANSITION ADD ON PPN MAX PRICE Composite Examination 70001* R 380 SINGLE VISION R 813 Consultation only R 345 BIFOCAL R Consultation & Tonometry R 360 MULTIFOCAL R Re-Examination R 275 Dispensing within the benefit 70005* R 125 FRAME PPN MAX PRICE CONTACT LENS CONSULTATIONS MED. AID PPN MAX PRICE Frame R 0 Contact Lens Re-Examination Bankmed R 190 FREE PPN frame R 150 Contact Lens Re-Examination Other R 150 FREE Practice frame PPN TARIFF 1 2 & 3 NVS Tag LAB Ref / Order Number V/A IOP VISFIELD REF R 150 PPN

4 Base Lens & Extras/Add-Ons 2012 These prices are the maximum amount that PPN will pay out towards the codes set out below PPN CR39 PRICE PPN GLASS PRICE BASE LENSES - PPN1 BASE LENSES - PPN Single Vision Lens - Aquity Base Lens R Single Vision Lens - Aquity Base Lens R Bifocal Lens - Aquity Base Lens R Bifocal Lens - Aquity Base Lens R Multifocal Lens - Aquity Base Lens R Multifocal Lens - Aquity Base Lens R 530 BASE LENSES - PPN2 BASE LENSES - PPN Single Vision Lens - Aquity Base Lens R Single Vision Lens - Aquity Base Lens R Bifocal Lens - Aquity Base Lens R Bifocal Lens - Aquity Base Lens R Multifocal Lens - Aquity Base Lens R Multifocal Lens - Aquity Base Lens R 655 ADD-ONS - LENSES ADD-ONS - LENSES Bifocal - Aspheric Lenticular/Elipsoid R Bifocal - Solid 38mm Seg R Bifocal - Executive 74mm R Bifocal - Executive 60mm R Trifocal - Flat-Top/Executive 74mm R Trifocal - Flat-Top 68x28 Seg R 583 ADD-ONS - TINTS & COATINGS ADD-ONS - TINTS & COATINGS Anti Reflex Coating Multi - Single Vision R Anti Reflex Coating Multi - Single Vision R Anti Reflex Coating Multi - Bifocal R Anti Reflex Coating Multi - Bifocal R Anti Reflex Coating Multi - Multifocal R Anti Reflex Coating Multi - Multifocal R Anti Reflex Coating Super - Single Vision R Anti Reflex Coating Super - Single Vision R Anti Reflex Coating Super - Bifocal R Anti Reflex Coating Super - Bifocal R Anti Reflex Coating Super - Multifocal R Anti Reflex Coating Super - Multifocal R Gradient tint < 50% - Single Vision R Fixed Tint<35% Single Vision R Gradient tint < 50% - Bifocal R Fixed Tint<35% - Bifocal R Gradient tint < 50% - Multifocal R Fixed Tint<35% - Multifocal R Gradient tint > 50% - Single Vision R Fixed Tint>35% Single Vision R Gradient tint > 50% - Bifocal R Fixed Tint>35% - Bifocal R Gradient tint > 50% - Multifocal R Fixed Tint>35% - Multifocal R Hardcoat - Single Vision R Hardcoat - Single Vision R Hardcoat - Bifocal R Hardcoat - Bifocal R Hardcoat - Multifocal R Hardcoat - Multifocal R Photocromic Tint - Single Vision R Photocromic Tint - Single Vision R Photocromic Tint - Bifocal R Photocromic Tint - Bifocal R Photocromic Tint - Multifocal R Photocromic Tint - Multifocal R Polarized R VAC Coat <35% Single Vision R Transitions - Single Vision R VAC Coat <35% - Bifocal R Transitions - Bifocal R VAC Coat <35% - Multifocal R Transitions - Multifocal R VAC Coat >35% R UV400 - Single Vision R Blue/Silver/Gold Mirror R UV400 - Bifocal R VC - Removal of Coating R UV400 - Multifocal R Removal Of Tint / Coating R Mirror Coat (Blue/Silver/Gold) R 575 ADD-ONS - POWERS ADD-ONS - POWERS Prism Fresnel R Prism Fresnel R Prism For Centration R Prism For Centration R Special Surfacing R Special Surfacing R 195 ADD-ONS - SPECIAL DESIGNS AND/OR MATERIALS ADD-ONS - SPECIAL DESIGNS m/m Seg Flat Top - Bifocal R Frosting R HRI up to 1.56 SV R HRI up to 1.6 SV R HRI up to 1.6 SV R HRI up to 1.7 SV R HRI up to 1.7 SV R HRI up to 1.8 SV R HRI up to 1.6 FTBF R HRI up to 1.6 FTBF R HRI Trivex 1.53 R HRI up to 1.7 FTBF R m/m Seg Flat Top - Trifocal R Special base curve R Frosting R Lenticular Concave R Special Base Curve R m/m Seg Flat Top - Bifocal R Lenticular Concave R m/m Seg Flat Top - Trifocal R Atoric/Aspheric Back Surface R HRI - Polycarbonate 1.6 R 741 Additional: Frame & Frame Extras/Add-Ons 2012 PPN DESCRIPTION PRICE PPN DESCRIPTION PRICE FRAMES INFORMATION TARIFFS Frame NVS Tag Information PPN Frame R Lab Number & Order Number Practice R150 Range R VA IOP Visual Field Readings FRAMES - SPECTACLE & SUNGLASSES FRAME MAINTENANCE PROCEDURES (Per Frame) Sunglasses Complete Realignment of Frame R Ready Made Readers SUNDRY WORKSHOP PROCEDURES (Per Lens) Spectacle Case Fitting Nylon / Rimless R 258 TRANSFERRING AT LABORATORY RISK TO IDENTICAL FRAME Alter/transfer Rimless R 277 (per pair of lenses) Frame Repairs or Sundry Items - to be specified Transfer - Nylon Supra or Rimless R 286 ACCOUNTING CODES Transfer - Zyl or Metal Frame R Medical Aid Benefit RE-EDGING, RE-SHAPING AND TRANSFERRING AT Discount LABORATORY RISK (per pair of lenses) Parcelling / Packaging or Delivering Re-Edge - Zyl Or Metal Frame R Re-Edge - Nylon Supra Frame/Rimless R Materials not listed (must be specified) PPN Tariff List PPN2 (Compiled CG )

5 Branded Lens Additions 01 Janaury 2012 POLYMER - SINGLE VISION GLASS - SINGLE VISION S/V BRANDED (Add to SV PPN 1 / 2) S/V BRANDED (Add to SV PPN 1 / 2) CODE GROUP DESCRIPTION PRICE CODE GROUP DESCRIPTION PRICE Group 1 SV CR39 Branded R Group 1 SV Glass Branded R Group 2 SV CR39 Branded R Group 2 SV Glass Branded R Group 3 SV CR39 Branded R Group 3 SV Glass Branded R Group 4 SV CR39 Branded R Group 4 SV Glass Branded R Group 5 SV CR39 Branded R Group 5 SV Glass Branded R Group 6 SV CR39 Branded R Group 6 SV Glass Branded R Group 7 SV CR39 Branded R Group 7 SV Glass Branded R Group 8 SV CR39 Branded R Group 8 SV Glass Branded R Group 9 SV CR39 Branded R Group 9 SV Glass Branded R Group 10 SV CR39 Branded R Group 11 SV CR39 Branded R GLASS - BIFOCAL Group 12 SV CR39 Branded R BI-TRIFOCAL (Add to PPN 1 / 2) Group 13 SV CR39 Branded R CODE GROUP DESCRIPTION PRICE Group 14 SV CR39 Branded R Group 1 Bi-Trifocal Glass Branded R Group 15 SV CR39 Branded R Group 2 Bi-Trifocal Glass Branded R Group 16 SV CR39 Branded R Group 3 Bi-Trifocal Glass Branded R Group 17 SV CR39 Branded R GLASS - MULTIFOCAL POLYMER - BIFOCAL VARIFOCAL BRANDED (Add to 26200(PPN1) or PPN2) BIFOCALS (Add to PPN 1 / 2) Varifocal Distance to Near R CODE GROUP DESCRIPTION PRICE CODE GROUP DESCRIPTION PRICE Group 1 BF CR39 Branded R Group 1 MF Glass Branded R Group 2 BF CR39 Branded R Group 2 MF Glass Branded R Group 3 BF CR39 Branded R Group 3 MF Glass Branded R Group 4 BF CR39 Branded R Group 4 MF Glass Branded R Group 5 BF CR39 Branded R Group 5 MF Glass Branded R Group 6 BF CR39 Branded R Group 6 MF Glass Branded R Group 7 BF CR39 Branded R Group 7 MF Glass Branded R Group 8 BF CR39 Branded R Group 8 MF Glass Branded R Group 9 BF CR39 Branded R Group 9 MF Glass Branded R Group 10 BF CR39 Branded R Group 10 MF Glass Branded R Group 11 MF Glass Branded R POLYMER - MULTIFOCAL Group 12 MF Glass Branded R VARIFOCAL BRANDED (Add to PPN R or Group 13 MF Glass Branded R PPN 2) Base Varifocal R Intermediate to Near R CODE GROUP DESCRIPTION PRICE Group 1 MF CR39 Branded R Group 2 MF CR39 Branded R Group 3 MF CR39 Branded R Group 4 MF CR39 Branded R Group 5 MF CR39 Branded R Group 6 MF CR39 Branded R Branded Add on Update: The 2011 Branded lens grid is still Group 7 MF CR39 Branded R applicable for PPN will forward you the updated FULL Group 8 MF CR39 Branded R branded lenses and categories as soon as possible Group 9 MF CR39 Branded R Group 10 MF CR39 Branded R Group 11 MF CR39 Branded R Group 12 MF CR39 Branded R Group 13 MF CR39 Branded R Group 14 MF CR39 Branded R Group 15 MF CR39 Branded R Group 16 MF CR39 Branded R Group 17 MF CR39 Branded R Group 18 MF CR39 Branded R Group 19 MF CR39 Branded R Group 20 MF CR39 Branded R PPN Tariff List PPN2 (Compiled CG )

6 PPN CONTACT LENS PRICES 1 JANUARY 2012 AVA CL EGP Each HDP Each HGP Each MGP Each PMMA Each BAUSCH & LOMB Optima 38 Each Optima Toric Stock Each Purevision 6-pack Purevision Multi Focal 6-pack Purevision Toric 6-pack Purevision 2 HD 6-pack Silsoft Each Soflens 38 6-pack Soflens 66 Toric 6-pack Soflens Comfort (Soflens 59) 6-pack Soflens Daily Disposable 10- pack Soflens Daily Disposable 30-pack Soflens Daily Disposable 90-pack Soflens Daily Disposable Toric 10-pack Soflens Daily Disposable Toric 30-pack Soflens Natural Colors 1-blister Softlens Multifocal 6-pack CIBA VISION Air Optix 6-pack Air Optix Aqua Hydrogel 6-pack Air Optix Aqua Multifocal 6-pack Air Optix Astigmatism 6-pack Air Optix Night & Day 6-pack Air Optix Night & Day Aqua 3 pack Air Optix Individual (3-monthly) 1-Pack Air Optix Individual (3-monthly) 2-Pack Focus Dailies 30-pack Focus Dailies 90-pack Focus Dailies Aqua Comfort Plus 30-pack Focus Dailies Aqua Comfort Plus 90-pack Focus Dailies Progressives 30-pack Focus Dailies Toric 30-pack Focus Monthly Softcolours 6-pack Focus Monthly Toric Visitint 6-pack Focus Monthly Visitint 6-pack Focus Progressives 6-pack Freshlook Colours 2-pack Freshlook ColourBlends 2-pack Freshlook Dimen (RX) 6-Pack Freshlook Dimension (plano) 2-pack Freshlook One Day Colour 10-pack Freshlook Radiance 2-pack

7 Precision UV 6-pack GENOP PMMA (C2,C3,Tricon,Pericon,Mina,Menicon) Each PMMA (C4, Tetracon,Aspheric) Each PMMA (Asticon,Keratocon,Multicurve, LDL) Each PMMA (Back Toric and Front Toric) Each LDK(C2,C3,Pricon,Mina,Menicon) Each LDK(C4,Tetracon,Aspheric (Jat) Each LDK(Asticon,Keratocon,Multicurve,LDL) Each LDK (Back Toric and Front Toric) Each MDK(C2,C3,Tricon,Pericon,Mina,Menicon) Each MDK (C4,Tetracon,Aspheric) Each MDK (Asticon, Keratocon,Multicurve, LDL) Each MDK Back Toric and Front Toric Each HDK (C2,C3,Tricon,Pericon,Mina,Menicon) Each HDK (C4,Tetracon,Aspheric) Each HDK (Asticon,Keratocon,Multicurve,LDL) Each HDK (Back Toric and Front Toric) Each Lenticular Each Prism Ballast Each Multiflow Bifocals Each Additional Toric Curve Each Inspection Each Analysis Each Service and Polish Each Chemical Cleaning and Polishing Each Cut Down/Reform Peripheral Each Convert to Aspheric Each Flattening/Extra Curving (Toric) Each Power Changes Each Edge Polish Each Blending Each Reforming Curves Each Fenistration Each GP Low DK-LDF10 Clear,Grey & Blue Each GP Med DK-LDF 30,40,Vista50,Fluroperm30,Paragon HDS Each GP High DK-Euro60,Paragon60,LDF90,Paragon HDS100 Each

8 COOPER VISION Switch/ Provision 6-pack Aquity II 6-pack Aquity PC 6-pack Aquity SI 6-pack Avaira Silicone Hydrogel 6-pack Biofinity Silicone Hydogel 6-pack Biofinity Toric 3-pack Biofinity Multifocal 6-pack Biomedics One Day Toric 30-pack Colour Tones 2-Pack Expressions Accents 3-pack Expressions Colors 3-pack Frequency XC/ Softique 6-pack Frequency 55 XCEL Toric 3-pack Frequency 55 Aspheric 6-pack Frequency 55 XCEL Toric XR 3-pack Hydrasoft Toric Each Healthy Vision Silicone Hydrogel 6-pack Images Tints 2-pack OmniFlex Toric Rx Each Proclear One Day 30-pack Proclear One Day 90-pack Proclear Multifocal 6-pack Proclear Multifocal Toric XR 3-pack Proclear Multifocal XR 3-pack Proclear Multifocal Toric XR Trial Singles Proclear Sphere 6-pack Proclear Sphere & RX Each Proclear Tailor Made Toric Rx Each Proclear Toric 6-pack Proclear Toric XR 3-pack Z 6 RP Toric Rx Each Z 67 Each Z 67 RP Toric Rx Each Zero Each Zero Each Zero 6 RX Each

9 EYE STYLE Adore Colour (Available from Sacks Optical) 2-pack Clear All Day 6-pack Clear 38 6-pack Clear 58 6-pack Clear 55A 6-pack Clear 1-Day 30-pack Clear All Day Toric 6-pack HINS Analyzing Each Biogel 60% Each Biogel 60% Lenticular Each Biogel 72% Each Biogel 72% Lenticular Each Blending Each Cleaning Each Convert to Aspheric Each Cut down and Reform Peripherical Each Edge Polish Each Fenestration Hard Lens (per hole) Each Fluroperm 60 Each Lenticulated Each Measure and Record Specs Each Power Changes Each Service and Polish Each SM 38 Each Toric Back Surface Each Toric Secondary Curve Each JOHNSON & JOHNSON Acuvue 2 6-pack Acuvue Advance / Hydraclear 6-pack Acuvue Oasis with Hydraclear 6-pack Acuvue Oasis for Astigmatism 6-pack Acuvue Moist for Astigmatism 30-pack Acuvue 1-Day 30-pack Acuvue Moist 1 Day 30-pack Acuvue Moist 1 Day 90-pack Acuvue True Eyes 1 Day 30-pack Acuvue Bifocal 6-pack Surevue (2-3 weeks delivery) 6-pack Twinkle 3 Tone 2-pack Twinkle 4 Tone 2-pack

10 SACKS OPTICAL Dispo Day-by-Day 32-pack Dispo Aspheric 6-pack Kristal 6-pack Dispo Toric 6-pack Dispo Multi 6-pack Expo Each Soft K Each Toric Eye-Q Each Toric-Lite Each CM GM3 Each SAUFLON Clear Comfort Aspheric 6-pack Sauflon 55 UV 6-pack New Day 1-Day 30-pack SPECIAL BRANDED Visaq 3 pack Oxyflow comfort 6 pack Xtensa 6 pack Mediflex 3 pack Mediflex Toric 3 pack Equilibria tailormade Toric - all RX's 2 pack Osmo 2 tailormade Toric - dry eye Px's 2 pack Ennovy 4T UV tailormade 2 pack Ennovy Elite MF tailormade 2 pack Minit 2 pack UltraWave (Edison) 6 pack Ultra T (Edison) 3 pack Kerasoft (Edison) Each ALK/PLASMA RGP (Edison- Hard cl) Each Kerasoft 3 (Edison- keratoconus) Each Hydrowave sphere & toric (Edison) Each TONY VINE Boston II Each LDF 25 Each PMMA Each XL 40 Each Aqueous Each Boston XO / EO Each LDF 50 Each Aspherics Each Bi - Toric Each Concentric Bifocal Each Hire of Fitting Set Each Lenticular Each Multiple Adjustments Each Single Adjustments Each Toric Base Curve Each Toric Front Curve Each Toric Second Curve Each

11 OTHER Contact lens Solutions Each Contact lens Accessories Each Materials not listed (Specify)

Archived SECTION 19 - PROCEDURE CODES. Section 19 - Procedure Codes

Archived SECTION 19 - PROCEDURE CODES. Section 19 - Procedure Codes SECTION 19 - EDURE CODES 19.1 CPT AND HCPCS CODES...3 19.2 PARTICIPANT COST SHARING AND COPAY...3 19.3 HCY/EPSDT VISION SCREENING...4 19.4 OPTICAL EDURE CODES...5 19.4.A EYE EXAMINATIONS...5 19.4.B FRAMES...5