Single-vision eyeglass lens, plano to ±4.00 diopter sphere

Hospitals report these codes with terse, inconsistent chargemaster text. This plain-English title was written by an AI model from that text and has not been reviewed by a person, so it can be wrong. The prices on this page come straight from hospital filings and do not depend on it.

Model: claude-haiku-5-5
Provider: anthropic
API: message_batches
Reasoning effort: low
Max output tokens: 4096
Prompt version (hash): 444523875572
Generated: October 20, 2026

Original text from hospital filings

Spherocylindr 4.00d/12-2.00d

Payers reporting HCPCS V2103

Payer pricing summary

Low

$10

Average

$57

Median

$51

High

$156

Payer rate distribution

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Filter by billing class

#
1	UnitedHealthcare fee schedule · outpatient · +13 other terms	338	$45	$47	$12	25%	—	$9 – $173
2	Aetna fee schedule · outpatient · +12 other terms	322	$45	$56	$32	57%	—	$18 – $348
3	Humana fee schedule · outpatient · +9 other terms	316	$50	$68	$70	103%	—	$33 – $343
4	Blue Cross Blue Shield fee schedule · outpatient · +6 other terms	213	$44	$58	$45	77%	—	$0 – $254
5	WellCare fee schedule · outpatient · +4 other terms	202	$46	$48	$12	24%	—	$41 – $108
6	Devoted fee schedule · outpatient · +2 other terms	164	$45	$45	$3	6%	—	$42 – $57
7	Cigna Healthspring fee schedule · outpatient · +1 other terms	116	$45	$46	$4	8%	—	$42 – $58
8	Molina fee schedule · outpatient · +5 other terms	110	$59	$62	$24	38%	—	$38 – $117
9	Cigna fee schedule · outpatient · +7 other terms	95	$50	$55	$20	36%	—	$41 – $140
10	Anthem fee schedule · outpatient · +7 other terms	74	$51	$51	$8	15%	—	$41 – $96
11	Kaiser fee schedule · outpatient · +4 other terms	61	$53	$81	$61	75%	—	$50 – $382
12	Superior Healthplan fee schedule · outpatient	40	$47	$47	$0	0%	—	$44 – $47
13	Clover fee schedule · outpatient · +2 other terms	37	$54	$49	$5	11%	—	$42 – $56
14	Ambetter facility · fee schedule · outpatient · +5 other terms	32	$86	$82	$17	21%	—	$41 – $104
15	Oscar fee schedule · outpatient · +3 other terms	32	$44	$50	$12	23%	—	$44 – $78
16	Optum fee schedule · outpatient · +3 other terms	26	$50	$54	$20	38%	—	$41 – $111
17	Caresource facility · case rate · outpatient · +4 other terms	20	$37	$50	$27	54%	—	$23 – $111
18	Regence facility · fee schedule · outpatient · +1 other terms	19	$54	$52	$3	6%	—	$43 – $55
19	Bcbs Tx fee schedule · outpatient	18	$44	$44	—	—	—	$44 – $44
20	Medicare fee schedule · outpatient · +1 other terms	18	$50	$50	$0	1%	—	$50 – $51
21	Amerihealth Caritas fee schedule · outpatient · +1 other terms	16	$50	$49	$1	2%	—	$47 – $50
22	Medical Mutual facility · fee schedule · outpatient · +1 other terms	15	$48	$55	$14	25%	—	$26 – $76
23	Bcbs Mn fee schedule · outpatient · +4 other terms	13	$44	$44	$10	23%	—	$21 – $51
24	Wellmark fee schedule · both · +1 other terms	13	$37	$38	$5	14%	—	$37 – $69
25	Aetna Better Health fee schedule · outpatient · +3 other terms	12	$39	$40	$1	2%	—	$39 – $41

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