| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
38 |
33 |
$3K |
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
40 |
33 |
$3K |
| V2020 |
Frames, purchases |
66 |
52 |
$2K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
22 |
14 |
$498.80 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
34 |
27 |
$447.00 |
| 92015 |
Determination of refractive state |
48 |
44 |
$251.00 |