| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
29 |
15 |
$379.72 |
| V2020 |
Frames, purchases |
59 |
59 |
$312.00 |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
26 |
13 |
$164.32 |
| 68801 |
|
60 |
60 |
$133.20 |
| 92083 |
|
111 |
111 |
$93.00 |
| 92250 |
|
117 |
117 |
$89.00 |
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
54 |
54 |
$80.00 |
| 92285 |
|
115 |
115 |
$56.58 |
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
64 |
64 |
$40.00 |
| 92286 |
|
97 |
97 |
$0.00 |
| 92025 |
|
119 |
119 |
$0.00 |
| 68761 |
|
17 |
17 |
$0.00 |