| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92012 |
|
1,207 |
1,114 |
$25K |
| 92250 |
|
578 |
571 |
$21K |
| 92133 |
|
112 |
112 |
$3K |
| 92083 |
|
111 |
110 |
$2K |
| 92004 |
|
2,283 |
2,280 |
$806.00 |
| 92014 |
|
4,150 |
4,141 |
$494.00 |
| 92020 |
|
13 |
13 |
$192.00 |
| V2784 |
Lens polycarb or equal |
6,643 |
3,295 |
$0.00 |
| V2100 |
Lens spher single plano 4.00 |
9,587 |
4,753 |
$0.00 |
| V2103 |
Spherocylindr 4.00d/12-2.00d |
1,471 |
757 |
$0.00 |
| V2200 |
Lens spher bifoc plano 4.00d |
1,202 |
589 |
$0.00 |
| V2744 |
Tint photochromatic lens/es |
204 |
102 |
$0.00 |
| V2781 |
Progressive lens per lens |
26 |
13 |
$0.00 |
| S0620 |
Routine ophthalmological exa |
31 |
31 |
$0.00 |
| V2299 |
Lens bifocal speciality |
26 |
13 |
$0.00 |
| V2020 |
Vision svcs frames purchases |
7,626 |
7,479 |
$0.00 |
| 92015 |
|
3,546 |
3,525 |
$0.00 |
| S0621 |
Routine ophthalmological exa |
74 |
74 |
$0.00 |
| V2750 |
Anti-reflective coating |
316 |
155 |
$0.00 |
| 2022F |
|
77 |
63 |
$0.00 |
| V2203 |
Lens sphcyl bifocal 4.00d/.1 |
258 |
127 |
$0.00 |