| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| S0621 |
Routine ophthalmological examination including refraction; established patient |
71 |
70 |
$3K |
| S0620 |
Routine ophthalmological examination including refraction; new patient |
37 |
37 |
$2K |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
18 |
18 |
$0.00 |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
43 |
43 |
$0.00 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
42 |
40 |
$0.00 |
| V2104 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens |
12 |
12 |
$0.00 |
| V2020 |
Frames, purchases |
43 |
43 |
$0.00 |