| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
877 |
456 |
$27K |
| V2783 |
Lens, index greater than or equal to 1.66 plastic or greater than or equal to 1.80 glass, excludes polycarbonate, per lens |
420 |
174 |
$19K |
| 92012 |
|
306 |
298 |
$8K |
| 92014 |
|
160 |
158 |
$7K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
381 |
193 |
$7K |
| 92015 |
|
963 |
945 |
$6K |
| V2020 |
Frames, purchases |
675 |
625 |
$5K |
| 92004 |
|
14 |
13 |
$1K |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
40 |
21 |
$600.00 |