| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
25 |
25 |
$680.00 |
| 92340 |
Fitting of spectacles, except for aphakia; monofocal |
36 |
31 |
$450.00 |
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
12 |
12 |
$440.00 |
| 92015 |
Determination of refractive state |
60 |
59 |
$364.00 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
36 |
31 |
$0.00 |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
12 |
12 |
$0.00 |
| V2020 |
Frames, purchases |
40 |
34 |
$0.00 |