| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2103 |
Spherocylindr 4.00d/12-2.00d |
3,970 |
2,541 |
$143K |
| V2020 |
Vision svcs frames purchases |
6,237 |
5,336 |
$129K |
| V2100 |
Lens spher single plano 4.00 |
1,777 |
1,310 |
$72K |
| V2115 |
Lens lenticular bifocal |
234 |
207 |
$20K |
| V2200 |
Lens spher bifoc plano 4.00d |
279 |
199 |
$15K |
| V2104 |
Spherocylindr 4.00d/2.12-4d |
203 |
151 |
$8K |
| V2025 |
Eyeglasses delux frames |
134 |
134 |
$8K |
| V2781 |
Progressive lens per lens |
267 |
154 |
$7K |
| V2520 |
Contact lens hydrophilic |
64 |
64 |
$5K |
| V2203 |
Lens sphcyl bifocal 4.00d/.1 |
79 |
55 |
$4K |
| V2750 |
Anti-reflective coating |
1,205 |
1,056 |
$2K |
| V2521 |
Cntct lens hydrophilic toric |
27 |
27 |
$2K |
| V2599 |
Contact lens/es other type |
25 |
25 |
$2K |
| V2784 |
Lens polycarb or equal |
656 |
340 |
$2K |
| V2107 |
Spherocylinder 4.25d/12-2d |
37 |
29 |
$1K |
| V2523 |
Cntct lens hydrophil extend |
12 |
12 |
$1K |
| V2744 |
Tint photochromatic lens/es |
276 |
192 |
$491.00 |