| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
150 |
49 |
$4K |
| V2020 |
Frames, purchases |
89 |
62 |
$2K |
| V2750 |
Anti-reflective coating, per lens |
108 |
38 |
$2K |
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
36 |
25 |
$752.70 |
| V2760 |
Scratch resistant coating, per lens |
34 |
12 |
$340.00 |
| 92015 |
Determination of refractive state |
30 |
25 |
$120.00 |
| 92083 |
|
30 |
28 |
$85.23 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
118 |
38 |
$60.00 |