| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2020 |
Frames, purchases |
28 |
28 |
$1K |
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
17 |
17 |
$640.00 |
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
15 |
15 |
$520.00 |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
24 |
17 |
$375.00 |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
19 |
14 |
$250.00 |
| 92015 |
Determination of refractive state |
14 |
14 |
$70.36 |