Provider Services and Products
Patient Costs and Benefits
Routine Exam U&C
Exam Copay
Refraction U&C
Hardware Copay
Exam Copay
$ 0.00
$ 5.00
$ 10.00
$ 15.00
$ 20.00
$ 25.00
Frame Out-of-pocket
Hardware Copay
$ 0.00
$ 5.00
$ 10.00
$ 15.00
$ 20.00
$ 25.00
Opth. Lens Out-of-pocket
Contact Lens Allowance
Contact Lens Out-of-pocket
Contact Lens Fitting U&C
Contact Lens U&C
Patient Responsibility
Frame Allowance
Frame U&C
Total Patient Benefit
Opth. Lens Allowance
Choose One
CR-39 Lenses
Add-On (per pair)
Choose One
Anti-Reflective Coating - V2750 ($40)
High Index - V2782, V2783 ($50)
Photochromatic/Transition - V2744 ($40)
Polycarbonate - V2784 ($35)
Progressive Lens - V2781 ($85)
Scratch Resistance - V2760 ($15)
Tint (solid or gradient) - V2745 ($15)
UV Treatment - V2755 ($15)
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Add-On (per pair)
Choose One
Anti-Reflective Coating - V2750 ($40)
High Index - V2782, V2783 ($50)
Photochromatic/Transition - V2744 ($40)
Polycarbonate - V2784 ($35)
Progressive Lens - V2781 ($85)
Scratch Resistance - V2760 ($15)
Tint (solid or gradient) - V2745 ($15)
UV Treatment - V2755 ($15)
Add-On (per pair)
Choose One
Anti-Reflective Coating - V2750 ($40)
High Index - V2782, V2783 ($50)
Photochromatic/Transition - V2744 ($40)
Polycarbonate - V2784 ($35)
Progressive Lens - V2781 ($85)
Scratch Resistance - V2760 ($15)
Tint (solid or gradient) - V2745 ($15)
UV Treatment - V2755 ($15)
Add-On (per pair)
Choose One
Anti-Reflective Coating - V2750 ($40)
High Index - V2782, V2783 ($50)
Photochromatic/Transition - V2744 ($40)
Polycarbonate - V2784 ($35)
Progressive Lens - V2781 ($85)
Scratch Resistance - V2760 ($15)
Tint (solid or gradient) - V2745 ($15)
UV Treatment - V2755 ($15)
Add-On (per pair)
Choose One
Anti-Reflective Coating - V2750 ($40)
High Index - V2782, V2783 ($50)
Photochromatic/Transition - V2744 ($40)
Polycarbonate - V2784 ($35)
Progressive Lens - V2781 ($85)
Scratch Resistance - V2760 ($15)
Tint (solid or gradient) - V2745 ($15)
UV Treatment - V2755 ($15)
Add-On (per pair)
Choose One
Anti-Reflective Coating - V2750 ($40)
High Index - V2782, V2783 ($50)
Photochromatic/Transition - V2744 ($40)
Polycarbonate - V2784 ($35)
Progressive Lens - V2781 ($85)
Scratch Resistance - V2760 ($15)
Tint (solid or gradient) - V2745 ($15)
UV Treatment - V2755 ($15)
Misc. Add-On
