| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
15 |
15 |
$720.00 |
| 92015 |
Determination of refractive state |
71 |
71 |
$643.74 |
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
12 |
12 |
$576.00 |
| 92340 |
Fitting of spectacles, except for aphakia; monofocal |
22 |
22 |
$440.00 |
| V2020 |
Frames, purchases |
22 |
22 |
$220.00 |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
13 |
13 |
$175.00 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
20 |
20 |
$60.00 |