| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
27 |
20 |
$2K |
| 92015 |
Determination of refractive state |
151 |
130 |
$2K |
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
17 |
12 |
$1K |
| V2020 |
Frames, purchases |
34 |
31 |
$951.75 |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
13 |
13 |
$328.56 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
15 |
13 |
$158.07 |
| V2750 |
Anti-reflective coating, per lens |
16 |
16 |
$45.00 |