| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| S0621 |
Routine ophthalmological examination including refraction; established patient |
186 |
184 |
$10K |
| S0620 |
Routine ophthalmological examination including refraction; new patient |
166 |
165 |
$8K |
| V2020 |
Frames, purchases |
480 |
474 |
$8K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
169 |
166 |
$4K |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
313 |
311 |
$2K |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
17 |
17 |
$323.44 |