| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92014 |
|
1,810 |
1,799 |
$133K |
| 92012 |
|
1,398 |
1,325 |
$75K |
| 92004 |
|
859 |
857 |
$71K |
| 92015 |
|
3,053 |
3,044 |
$39K |
| 92340 |
|
2,003 |
2,000 |
$38K |
| 92250 |
|
544 |
542 |
$17K |
| 92083 |
|
441 |
441 |
$16K |
| 92275 |
|
113 |
113 |
$11K |
| 66984 |
|
28 |
26 |
$9K |
| 92133 |
|
248 |
248 |
$5K |
| 92226 |
|
377 |
207 |
$5K |
| 92134 |
|
202 |
202 |
$4K |
| 99213 |
|
85 |
82 |
$4K |
| 92225 |
|
159 |
90 |
$3K |
| 99214 |
|
30 |
30 |
$2K |
| 92136 |
|
38 |
37 |
$981.40 |
| 92002 |
|
16 |
16 |
$843.98 |
| 92020 |
|
54 |
54 |
$829.96 |
| V2020 |
Vision svcs frames purchases |
493 |
493 |
$820.00 |
| 92235 |
|
22 |
14 |
$803.16 |
| 92060 |
|
13 |
12 |
$555.39 |
| 92285 |
|
39 |
37 |
$363.76 |
| 92025 |
|
14 |
14 |
$348.16 |
| 76514 |
|
34 |
34 |
$336.60 |
| V2784 |
Lens polycarb or equal |
460 |
280 |
$273.60 |
| V2100 |
Lens spher single plano 4.00 |
281 |
175 |
$252.00 |
| V2755 |
Uv lens/es |
14 |
14 |
$222.30 |
| S0620 |
Routine ophthalmological exa |
140 |
140 |
$0.00 |
| V2200 |
Lens spher bifoc plano 4.00d |
26 |
14 |
$0.00 |
| V2104 |
Spherocylindr 4.00d/2.12-4d |
56 |
35 |
$0.00 |
| V2103 |
Spherocylindr 4.00d/12-2.00d |
311 |
185 |
$0.00 |
| V2744 |
Tint photochromatic lens/es |
51 |
32 |
$0.00 |
| S0621 |
Routine ophthalmological exa |
221 |
221 |
$0.00 |
| V2203 |
Lens sphcyl bifocal 4.00d/.1 |
100 |
58 |
$0.00 |
| V2750 |
Anti-reflective coating |
314 |
187 |
$0.00 |