| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
119 |
119 |
$9K |
| S0621 |
Routine ophthalmological examination including refraction; established patient |
84 |
84 |
$4K |
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
30 |
30 |
$1K |
| V2025 |
Deluxe frame |
55 |
53 |
$1K |
| V2760 |
Scratch resistant coating, per lens |
41 |
41 |
$820.00 |
| V2750 |
Anti-reflective coating, per lens |
12 |
12 |
$403.00 |
| V2020 |
Frames, purchases |
15 |
15 |
$133.44 |