| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92015 |
Determination of refractive state |
132 |
120 |
$2K |
| V2020 |
Frames, purchases |
70 |
64 |
$2K |
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
26 |
24 |
$990.00 |
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
16 |
16 |
$720.00 |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
53 |
28 |
$383.67 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
46 |
42 |
$122.50 |