| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2020 |
Frames, purchases |
753 |
690 |
$13K |
| S0621 |
Routine ophthalmological examination including refraction; established patient |
196 |
196 |
$8K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
395 |
366 |
$7K |
| V2744 |
Tint, photochromatic, per lens |
132 |
129 |
$5K |
| V2750 |
Anti-reflective coating, per lens |
208 |
203 |
$5K |
| S0620 |
Routine ophthalmological examination including refraction; new patient |
69 |
69 |
$3K |
| V2025 |
Deluxe frame |
13 |
13 |
$873.21 |
| V2203 |
Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
28 |
28 |
$711.56 |
| 92015 |
Determination of refractive state |
34 |
34 |
$548.06 |
| V2104 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens |
31 |
27 |
$459.97 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
50 |
50 |
$442.96 |