| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2410 |
Variable asphericity lens, single vision, full field, glass or plastic, per lens |
26 |
15 |
$3K |
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
26 |
24 |
$3K |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
26 |
15 |
$2K |
| V2025 |
Deluxe frame |
26 |
15 |
$2K |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
20 |
12 |
$2K |
| V2750 |
Anti-reflective coating, per lens |
26 |
15 |
$906.88 |
| V2755 |
U-v lens, per lens |
26 |
15 |
$861.12 |
| 92340 |
Fitting of spectacles, except for aphakia; monofocal |
26 |
15 |
$690.82 |
| 92015 |
Determination of refractive state |
97 |
97 |
$0.00 |