| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2103 |
Spherocylindr 4.00d/12-2.00d |
11,665 |
10,514 |
$158K |
| V2020 |
Vision svcs frames purchases |
13,314 |
11,822 |
$150K |
| V2025 |
Eyeglasses delux frames |
4,745 |
4,480 |
$117K |
| V2104 |
Spherocylindr 4.00d/2.12-4d |
3,202 |
2,896 |
$38K |
| V2784 |
Lens polycarb or equal |
2,977 |
2,729 |
$37K |
| V2100 |
Lens spher single plano 4.00 |
2,590 |
2,321 |
$27K |
| V2105 |
Spherocylinder 4.00d/4.25-6d |
691 |
628 |
$18K |
| V2107 |
Spherocylinder 4.25d/12-2d |
1,508 |
1,326 |
$18K |
| V2203 |
Lens sphcyl bifocal 4.00d/.1 |
1,022 |
847 |
$15K |
| V2108 |
Spherocylinder 4.25d/2.12-4d |
250 |
232 |
$3K |
| V2744 |
Tint photochromatic lens/es |
199 |
179 |
$1K |
| V2750 |
Anti-reflective coating |
253 |
234 |
$629.24 |
| V2799 |
Misc vision item or service |
185 |
167 |
$353.52 |
| V2101 |
Single visn sphere 4.12-7.00 |
13 |
13 |
$154.11 |
| V2781 |
Progressive lens per lens |
16 |
12 |
$0.00 |