| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
773 |
540 |
$15K |
| V2020 |
Frames, purchases |
675 |
514 |
$12K |
| 92014 |
|
169 |
147 |
$9K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
493 |
352 |
$6K |
| 92004 |
|
101 |
85 |
$4K |
| 92015 |
|
558 |
475 |
$2K |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
156 |
98 |
$2K |
| V2104 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens |
12 |
12 |
$306.00 |