| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| S0620 |
Routine ophthalmological examination including refraction; new patient |
67 |
67 |
$3K |
| V2020 |
Frames, purchases |
139 |
139 |
$2K |
| S0621 |
Routine ophthalmological examination including refraction; established patient |
40 |
40 |
$2K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
81 |
81 |
$1K |
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
17 |
17 |
$510.00 |
| 92015 |
Determination of refractive state |
147 |
147 |
$400.00 |
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
12 |
12 |
$360.00 |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
20 |
20 |
$202.50 |