| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2020 |
Frames, purchases |
350 |
348 |
$2K |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
86 |
84 |
$856.46 |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
195 |
195 |
$621.60 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
15 |
15 |
$610.37 |
| 92015 |
|
521 |
519 |
$245.70 |
| S0580 |
Polycarbonate lens (list this code in addition to the basic code for the lens) |
330 |
328 |
$180.00 |
| V2104 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens |
57 |
57 |
$0.00 |
| 92004 |
|
123 |
123 |
$0.00 |
| 92014 |
|
286 |
286 |
$0.00 |
| 92340 |
|
327 |
325 |
$0.00 |
| V2410 |
Variable asphericity lens, single vision, full field, glass or plastic, per lens |
232 |
230 |
$0.00 |
| 92012 |
|
38 |
38 |
$0.00 |