| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92014 |
|
603 |
603 |
$27K |
| 92004 |
|
419 |
416 |
$19K |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
346 |
337 |
$14K |
| V2020 |
Frames, purchases |
120 |
120 |
$7K |
| V2025 |
Deluxe frame |
74 |
74 |
$3K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
14 |
12 |
$676.00 |
| S0621 |
Routine ophthalmological examination including refraction; established patient |
12 |
12 |
$540.00 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
15 |
15 |
$50.00 |
| 92015 |
|
364 |
363 |
$0.00 |