| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92004 |
|
2,053 |
2,043 |
$148K |
| V2020 |
Frames, purchases |
4,374 |
4,327 |
$116K |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
3,567 |
1,872 |
$79K |
| 92014 |
|
912 |
902 |
$48K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
665 |
600 |
$29K |
| V2200 |
Sphere, bifocal, plano to plus or minus 4.00d, per lens |
658 |
334 |
$19K |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
5,346 |
2,775 |
$9K |
| 92340 |
|
141 |
139 |
$2K |
| V2203 |
Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
13 |
12 |
$1K |
| 92015 |
|
388 |
385 |
$762.75 |