| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
1,672 |
1,667 |
$139K |
| V2020 |
Frames, purchases |
1,659 |
1,654 |
$109K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
699 |
699 |
$43K |
| V2104 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens |
486 |
485 |
$30K |
| V2105 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 4.25 to 6.00d cylinder, per lens |
84 |
84 |
$6K |