| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92004 |
|
930 |
923 |
$57K |
| V2020 |
Frames, purchases |
798 |
795 |
$26K |
| 92340 |
|
642 |
640 |
$21K |
| 92250 |
|
343 |
343 |
$21K |
| 92015 |
|
1,009 |
1,008 |
$12K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
221 |
221 |
$8K |
| 99214 |
|
108 |
94 |
$5K |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
88 |
88 |
$2K |
| V2750 |
Anti-reflective coating, per lens |
13 |
13 |
$717.60 |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
25 |
25 |
$592.92 |
| 92014 |
|
13 |
13 |
$426.00 |