| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
40 |
40 |
$1K |
| V2020 |
Frames, purchases |
55 |
55 |
$1K |
| 92015 |
Determination of refractive state |
157 |
157 |
$839.95 |
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
14 |
14 |
$718.90 |
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
12 |
12 |
$616.20 |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
13 |
13 |
$238.14 |