| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92014 |
|
622 |
554 |
$27K |
| 92004 |
|
463 |
376 |
$19K |
| V2020 |
Frames, purchases |
441 |
359 |
$7K |
| 92015 |
|
864 |
723 |
$4K |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
302 |
141 |
$3K |
| V2104 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens |
115 |
58 |
$3K |
| 92340 |
|
303 |
293 |
$2K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
122 |
54 |
$894.74 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
42 |
12 |
$335.06 |
| 3072F |
|
79 |
53 |
$0.00 |