| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92004 |
|
1,541 |
1,504 |
$140K |
| 92014 |
|
1,869 |
1,808 |
$125K |
| V2020 |
Frames, purchases |
2,230 |
2,114 |
$65K |
| 92340 |
|
1,858 |
1,822 |
$55K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
1,349 |
1,280 |
$22K |
| 92015 |
|
2,502 |
2,406 |
$11K |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
1,306 |
1,251 |
$9K |
| V2760 |
Scratch resistant coating, per lens |
1,153 |
1,129 |
$2K |
| 92250 |
|
40 |
36 |
$1K |
| V2203 |
Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
53 |
47 |
$1K |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
84 |
83 |
$1K |
| 92341 |
|
62 |
59 |
$882.34 |
| 92310 |
|
24 |
24 |
$540.00 |
| 92370 |
|
14 |
14 |
$406.00 |
| S0504 |
Single vision prescription lens (safety, athletic, or sunglass), per lens |
12 |
12 |
$110.10 |
| S9999 |
Sales tax |
12 |
12 |
$20.55 |