| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2025 |
Deluxe frame |
1,620 |
1,620 |
$120K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
1,291 |
1,290 |
$21K |
| V2750 |
Anti-reflective coating, per lens |
1,035 |
1,035 |
$8K |
| V2104 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens |
229 |
228 |
$3K |
| V2020 |
Frames, purchases |
121 |
120 |
$2K |
| V2744 |
Tint, photochromatic, per lens |
41 |
41 |
$769.56 |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
18 |
18 |
$274.95 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
25 |
25 |
$254.76 |