| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| S0621 |
Routine ophthalmological examination including refraction; established patient |
376 |
376 |
$22K |
| V2020 |
Frames, purchases |
571 |
565 |
$11K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
300 |
299 |
$8K |
| S0620 |
Routine ophthalmological examination including refraction; new patient |
134 |
134 |
$7K |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
161 |
161 |
$5K |
| 92014 |
|
27 |
27 |
$3K |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
88 |
87 |
$2K |
| 92012 |
|
31 |
30 |
$2K |
| 92004 |
|
12 |
12 |
$1K |
| 92015 |
|
67 |
66 |
$1K |
| V2104 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens |
26 |
26 |
$578.90 |