| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
12 |
12 |
$887.36 |
| 92340 |
Fitting of spectacles, except for aphakia; monofocal |
35 |
35 |
$700.00 |
| V2020 |
Frames, purchases |
35 |
35 |
$372.50 |
| 92015 |
Determination of refractive state |
28 |
28 |
$366.65 |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
13 |
13 |
$152.00 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
34 |
34 |
$83.50 |