| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
228 |
214 |
$13K |
| V2020 |
Frames, purchases |
55 |
53 |
$3K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
15 |
13 |
$847.50 |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
17 |
16 |
$529.54 |
| 92015 |
Determination of refractive state |
128 |
125 |
$421.74 |
| V2025 |
Deluxe frame |
16 |
15 |
$375.00 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
26 |
26 |
$344.90 |