| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2020 |
Frames, purchases |
2,228 |
2,215 |
$70K |
| V2025 |
Deluxe frame |
516 |
514 |
$24K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
1,409 |
1,401 |
$23K |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
474 |
470 |
$8K |
| V2750 |
Anti-reflective coating, per lens |
814 |
807 |
$6K |
| V2104 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens |
217 |
217 |
$3K |
| S0620 |
Routine ophthalmological examination including refraction; new patient |
13 |
13 |
$570.00 |
| V2203 |
Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
13 |
13 |
$460.00 |
| V2105 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 4.25 to 6.00d cylinder, per lens |
12 |
12 |
$181.00 |
| V2744 |
Tint, photochromatic, per lens |
12 |
12 |
$85.00 |
| V2799 |
Vision item or service, miscellaneous |
57 |
57 |
$20.00 |