| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
14 |
13 |
$969.99 |
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
14 |
14 |
$925.78 |
| 92340 |
Fitting of spectacles, except for aphakia; monofocal |
21 |
21 |
$577.66 |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
40 |
20 |
$520.96 |
| V2020 |
Frames, purchases |
21 |
21 |
$491.37 |
| 92015 |
Determination of refractive state |
41 |
40 |
$375.49 |