| Code | Description | Claims | Beneficiaries | Total Paid |
| V2744 |
Tint, photochromatic, per lens |
1,764 |
1,758 |
$68K |
| S0621 |
Routine ophthalmological examination including refraction; established patient |
1,425 |
1,423 |
$61K |
| V2020 |
Frames, purchases |
3,392 |
3,382 |
$51K |
| V2203 |
Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
1,460 |
1,454 |
$39K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
1,912 |
1,908 |
$34K |
| S0620 |
Routine ophthalmological examination including refraction; new patient |
569 |
568 |
$24K |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
1,071 |
1,069 |
$20K |
| V2750 |
Anti-reflective coating, per lens |
112 |
112 |
$3K |
| V2781 |
Progressive lens, per lens |
13 |
13 |
$530.32 |
| V2799 |
Vision item or service, miscellaneous |
36 |
36 |
$150.60 |