| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
196 |
160 |
$8K |
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
109 |
92 |
$6K |
| 76512 |
|
32 |
16 |
$2K |
| 92250 |
|
25 |
25 |
$937.08 |
| V2020 |
Frames, purchases |
15 |
15 |
$452.50 |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
26 |
13 |
$451.24 |
| 92015 |
Determination of refractive state |
64 |
64 |
$199.50 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
26 |
13 |
$0.00 |