| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92004 |
|
517 |
517 |
$38K |
| V2020 |
Frames, purchases |
1,455 |
1,452 |
$21K |
| V2782 |
Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate, per lens |
342 |
340 |
$20K |
| 92340 |
|
1,415 |
1,412 |
$19K |
| 92015 |
|
510 |
508 |
$6K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
542 |
540 |
$5K |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
608 |
607 |
$5K |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
105 |
105 |
$4K |
| 92014 |
|
63 |
63 |
$4K |
| S0580 |
Polycarbonate lens (list this code in addition to the basic code for the lens) |
204 |
204 |
$3K |
| 92012 |
|
15 |
15 |
$595.20 |
| V2203 |
Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
14 |
14 |
$289.80 |