| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2020 |
Frames, purchases |
129 |
88 |
$2K |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
88 |
72 |
$2K |
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
28 |
28 |
$1K |
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
16 |
16 |
$687.36 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
16 |
16 |
$150.00 |
| 92015 |
Determination of refractive state |
86 |
86 |
$0.00 |