| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
78 |
78 |
$3K |
| V2020 |
Frames, purchases |
116 |
116 |
$2K |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
80 |
80 |
$2K |
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
12 |
12 |
$509.41 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
12 |
12 |
$130.00 |
| 92015 |
Determination of refractive state |
174 |
172 |
$14.85 |