| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| S0621 |
Routine ophthalmological exa |
1,923 |
1,922 |
$88K |
| V2025 |
Eyeglasses delux frames |
1,087 |
1,085 |
$66K |
| V2020 |
Vision svcs frames purchases |
2,185 |
2,161 |
$44K |
| S0620 |
Routine ophthalmological exa |
922 |
922 |
$41K |
| V2103 |
Spherocylindr 4.00d/12-2.00d |
1,644 |
1,635 |
$34K |
| V2104 |
Spherocylindr 4.00d/2.12-4d |
676 |
673 |
$12K |
| V2100 |
Lens spher single plano 4.00 |
497 |
495 |
$9K |
| V2105 |
Spherocylinder 4.00d/4.25-6d |
141 |
141 |
$4K |
| V2523 |
Cntct lens hydrophil extend |
25 |
24 |
$3K |
| V2784 |
Lens polycarb or equal |
88 |
88 |
$2K |
| V2203 |
Lens sphcyl bifocal 4.00d/.1 |
25 |
25 |
$1K |
| V2107 |
Spherocylinder 4.25d/12-2d |
12 |
12 |
$185.09 |