| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2020 |
Frames, purchases |
55 |
54 |
$2K |
| V2025 |
Deluxe frame |
13 |
13 |
$1K |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
13 |
13 |
$966.26 |
| 92340 |
Fitting of spectacles, except for aphakia; monofocal |
40 |
39 |
$946.44 |
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
12 |
12 |
$849.10 |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
41 |
40 |
$723.50 |
| 92015 |
Determination of refractive state |
50 |
49 |
$133.00 |