| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2020 |
Frames, purchases |
123 |
113 |
$4K |
| 92012 |
Ophthalmological services: medical examination and evaluation, intermediate, established patient |
15 |
15 |
$4K |
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
40 |
40 |
$3K |
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
21 |
21 |
$2K |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
57 |
51 |
$2K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
33 |
33 |
$886.50 |
| 92015 |
Determination of refractive state |
131 |
130 |
$548.10 |
| S0580 |
Polycarbonate lens (list this code in addition to the basic code for the lens) |
81 |
71 |
$540.00 |
| V2782 |
Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate, per lens |
14 |
14 |
$469.98 |
| V2107 |
Spherocylinder, single vision, plus or minus 4.25 to plus or minus 7.00 sphere, .12 to 2.00d cylinder, per lens |
12 |
12 |
$383.52 |
| V2760 |
Scratch resistant coating, per lens |
46 |
36 |
$272.00 |
| V2755 |
U-v lens, per lens |
15 |
15 |
$49.00 |