| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
30 |
30 |
$1K |
| V2020 |
Frames, purchases |
56 |
56 |
$830.00 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
26 |
26 |
$562.50 |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
15 |
15 |
$373.20 |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
12 |
12 |
$240.00 |
| 92015 |
Determination of refractive state |
18 |
18 |
$0.00 |