| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92004 |
|
643 |
641 |
$25K |
| 92014 |
|
623 |
621 |
$25K |
| V2020 |
Frames, purchases |
434 |
424 |
$5K |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
290 |
281 |
$4K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
281 |
272 |
$4K |
| 92310 |
|
25 |
25 |
$1K |
| V2104 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens |
26 |
26 |
$400.00 |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
12 |
12 |
$170.00 |
| 92015 |
|
806 |
805 |
$0.00 |