| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2020 |
Frames, purchases |
120 |
120 |
$8K |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
46 |
46 |
$2K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
24 |
24 |
$1K |
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
13 |
13 |
$1K |
| 92015 |
Determination of refractive state |
51 |
51 |
$902.89 |
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
12 |
12 |
$780.00 |