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