| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
17 |
17 |
$487.63 |
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
12 |
12 |
$311.78 |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
16 |
15 |
$0.00 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
12 |
12 |
$0.00 |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
21 |
12 |
$0.00 |
| V2020 |
Frames, purchases |
34 |
33 |
$0.00 |
| 92015 |
Determination of refractive state |
48 |
48 |
$0.00 |
| V2025 |
Deluxe frame |
14 |
14 |
$0.00 |