| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| V2020 |
Frames, purchases |
2,798 |
2,640 |
$70K |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
1,334 |
1,295 |
$21K |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
308 |
307 |
$7K |
| V2203 |
Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
172 |
172 |
$6K |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
352 |
341 |
$5K |
| V2750 |
Anti-reflective coating, per lens |
200 |
200 |
$4K |
| V2107 |
Spherocylinder, single vision, plus or minus 4.25 to plus or minus 7.00 sphere, .12 to 2.00d cylinder, per lens |
13 |
13 |
$265.00 |