| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2020 |
Frames, purchases |
505 |
504 |
$7K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
299 |
299 |
$7K |
| V2203 |
Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
68 |
68 |
$3K |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
133 |
133 |
$3K |
| V2107 |
Spherocylinder, single vision, plus or minus 4.25 to plus or minus 7.00 sphere, .12 to 2.00d cylinder, per lens |
31 |
31 |
$551.50 |
| V2104 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens |
16 |
16 |
$319.00 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
33 |
33 |
$124.64 |
| V2755 |
U-v lens, per lens |
33 |
33 |
$0.00 |
| V2799 |
Vision item or service, miscellaneous |
15 |
15 |
$0.00 |
| V2750 |
Anti-reflective coating, per lens |
64 |
64 |
$0.00 |