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    Invoice: Patient Name: Order # 28798120 Insurance: VSP CHOICE PLAN

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    UniqueEye Optique
    This invoice is from Jerome Kramer OD for eye care services provided to Charles Thompson on March 31, 2023. It details various tests, procedures, and products provided including a refraction for $65, corneal topography for $60, an OCT wellness scan for $79, custom scleral lenses for $360 with a $100 insurance allowance, and a priority flat rate of $20 after a $5 discount. The total due was $774 which was paid in full by Charles Thompson.

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    Invoice: Patient Name: Order # 28798120 Insurance: VSP CHOICE PLAN

    Uploaded by

    UniqueEye Optique
    30 views2 pages
    This invoice is from Jerome Kramer OD for eye care services provided to Charles Thompson on March 31, 2023. It details various tests, procedures, and products provided including a refraction for $65, corneal topography for $60, an OCT wellness scan for $79, custom scleral lenses for $360 with a $100 insurance allowance, and a priority flat rate of $20 after a $5 discount. The total due was $774 which was paid in full by Charles Thompson.

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    This invoice is from Jerome Kramer OD for eye care services provided to Charles Thompson on March 31, 2023. It details various tests, procedures, and products provided including a refraction for $65, corneal topography for $60, an OCT wellness scan for $79, custom scleral lenses for $360 with a $100 insurance allowance, and a priority flat rate of $20 after a $5 discount. The total due was $774 which was paid in full by Charles Thompson.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    30 views2 pages

    Invoice: Patient Name: Order # 28798120 Insurance: VSP CHOICE PLAN

    Uploaded by

    UniqueEye Optique
    This invoice is from Jerome Kramer OD for eye care services provided to Charles Thompson on March 31, 2023. It details various tests, procedures, and products provided including a refraction for $65, corneal topography for $60, an OCT wellness scan for $79, custom scleral lenses for $360 with a $100 insurance allowance, and a priority flat rate of $20 after a $5 discount. The total due was $774 which was paid in full by Charles Thompson.

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    © All Rights Reserved
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    Invoice

    JEROME KRAMER OD FAAO


    175 I U WILLETS RD
    Albertson, NY 115071342
    (516) 333-0222

    Office # : 0045918
    Service Date: 03/31/2023
    Payment #: 37568844
    Patient Name: Charles Thompson Employee : 16
    9 Kathryn Street Provider Name: Jerome Kramer
    Lynbrook, NY 11501 NPI: 1437259637
    Item/ Service Description Proc Code Diagnosis Codes Retail Price Discount Insurance Allowance Insurance Copay Patient Due
    Patient Name: Charles Thompson
    Order # 28798120 Insurance: VSP CHOICE PLAN

    Refraction - 92015 92015 H52.13 $65.00 $65.00 $0.00

    92025 - Corneal 92025 H52.13 $60.00 $60.00


    Topography - 92025

    Wellness Scan - OCT OCT H52.13 $79.00 $79.00

    Custom (Scleral GP V2531 H52.13 $360.00 $100.00 $260.00


    Designs) - LMD

    Priority Flat Rate H52.13 $25.00 $5.00 $20.00

    PSA H52.13 $355.00 $355.00

    Total $944.00 $5.00 $165.00 $0.00 $774.00

    Your savings with VSP : | $170.00

    Manual Tax $0.00


    Total Tax/Fee $0.00

    Payment History
    Amount shown may exceed the total payment amount on this invoice if the payment was
    applied to multiple orders
    TransactionDate CustomerName Amount Type
    3/31/2023 5:24:07 PM Charles Thompson $774.00 Discover
    Payments Summary
    Total Due $774.00
    Total Payments Made ($774.00)
    Total Adjustments $0.00
    Balance $0.00

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