| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2020 |
Frames, purchases |
194 |
193 |
$779.50 |
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
75 |
75 |
$758.85 |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
140 |
70 |
$595.12 |
| S0621 |
Routine ophthalmological examination including refraction; established patient |
14 |
14 |
$200.00 |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
32 |
16 |
$82.16 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
136 |
68 |
$0.00 |
| V2755 |
U-v lens, per lens |
150 |
75 |
$0.00 |