| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
77 |
52 |
$2K |
| V2020 |
Frames, purchases |
67 |
66 |
$956.35 |
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
12 |
12 |
$614.37 |
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
12 |
12 |
$508.00 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
43 |
25 |
$52.00 |
| 92015 |
Determination of refractive state |
30 |
30 |
$0.00 |