| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
194 |
191 |
$24K |
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
188 |
187 |
$19K |
| V2025 |
Deluxe frame |
217 |
217 |
$11K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
195 |
193 |
$6K |
| 92015 |
Determination of refractive state |
353 |
350 |
$5K |
| V2020 |
Frames, purchases |
35 |
35 |
$561.05 |