| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2025 |
Deluxe frame |
359 |
269 |
$10K |
| 92340 |
Fitting of spectacles, except for aphakia; monofocal |
139 |
121 |
$4K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
131 |
104 |
$1K |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
127 |
106 |
$1K |
| V2203 |
Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
61 |
44 |
$832.00 |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
20 |
20 |
$234.00 |
| V2750 |
Anti-reflective coating, per lens |
31 |
30 |
$0.00 |