| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| S0621 |
Routine ophthalmological examination including refraction; established patient |
135 |
135 |
$8K |
| S0620 |
Routine ophthalmological examination including refraction; new patient |
79 |
79 |
$4K |
| V2020 |
Frames, purchases |
70 |
70 |
$200.00 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
12 |
12 |
$143.00 |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
15 |
15 |
$140.00 |
| S9986 |
Not medically necessary service (patient is aware that service not medically necessary) |
12 |
12 |
$0.00 |
| 92015 |
Determination of refractive state |
58 |
58 |
$0.00 |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
92 |
92 |
$0.00 |