| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
75 |
75 |
$5K |
| V2020 |
Frames, purchases |
134 |
132 |
$4K |
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
32 |
32 |
$3K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
42 |
42 |
$1K |
| 92015 |
Determination of refractive state |
133 |
133 |
$793.80 |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
13 |
13 |
$326.56 |
| S0580 |
Polycarbonate lens (list this code in addition to the basic code for the lens) |
43 |
43 |
$250.00 |