| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92250 |
|
124 |
113 |
$5K |
| 92015 |
Determination of refractive state |
274 |
262 |
$5K |
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
85 |
85 |
$4K |
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
26 |
26 |
$1K |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
18 |
14 |
$1K |
| 92012 |
Ophthalmological services: medical examination and evaluation, intermediate, established patient |
19 |
19 |
$855.00 |
| V2025 |
Deluxe frame |
19 |
15 |
$215.40 |