| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| S0621 |
Routine ophthalmological examination including refraction; established patient |
266 |
261 |
$11K |
| V2025 |
Deluxe frame |
196 |
192 |
$5K |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
272 |
265 |
$5K |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
89 |
89 |
$1K |
| S0620 |
Routine ophthalmological examination including refraction; new patient |
30 |
30 |
$1K |
| V2750 |
Anti-reflective coating, per lens |
31 |
30 |
$310.55 |
| 92015 |
Determination of refractive state |
12 |
12 |
$10.00 |