| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2020 |
Frames, purchases |
279 |
257 |
$613.00 |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
138 |
138 |
$424.00 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
12 |
12 |
$44.00 |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
146 |
142 |
$0.00 |
| V2799 |
Vision item or service, miscellaneous |
16 |
15 |
$0.00 |
| V2105 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 4.25 to 6.00d cylinder, per lens |
12 |
12 |
$0.00 |
| V2104 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens |
55 |
52 |
$0.00 |
| V2025 |
Deluxe frame |
291 |
288 |
$0.00 |
| V2750 |
Anti-reflective coating, per lens |
78 |
77 |
$0.00 |