| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2020 |
Frames, purchases |
348 |
340 |
$24K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
87 |
87 |
$3K |
| S0621 |
Routine ophthalmological examination including refraction; established patient |
49 |
48 |
$1K |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
21 |
18 |
$1K |
| S0620 |
Routine ophthalmological examination including refraction; new patient |
32 |
32 |
$960.00 |
| V2025 |
Deluxe frame |
24 |
24 |
$285.12 |
| V2755 |
U-v lens, per lens |
13 |
13 |
$100.00 |