| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
36 |
36 |
$3K |
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
13 |
13 |
$2K |
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
13 |
12 |
$1K |
| 92015 |
Determination of refractive state |
42 |
42 |
$568.48 |
| S0621 |
Routine ophthalmological examination including refraction; established patient |
12 |
12 |
$540.00 |
| V2750 |
Anti-reflective coating, per lens |
12 |
12 |
$498.00 |