| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
97 |
97 |
$551.00 |
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
130 |
130 |
$161.80 |
| V2020 |
Frames, purchases |
280 |
280 |
$60.00 |
| 92015 |
Determination of refractive state |
12 |
12 |
$33.00 |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
22 |
12 |
$21.00 |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
169 |
104 |
$0.00 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
196 |
114 |
$0.00 |
| S0620 |
Routine ophthalmological examination including refraction; new patient |
35 |
35 |
$0.00 |
| S0621 |
Routine ophthalmological examination including refraction; established patient |
15 |
15 |
$0.00 |