| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
255 |
253 |
$11K |
| 92015 |
Determination of refractive state |
414 |
409 |
$9K |
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
14 |
14 |
$688.66 |
| V2020 |
Frames, purchases |
23 |
23 |
$460.00 |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
18 |
18 |
$408.00 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
24 |
24 |
$138.00 |