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  • Invoice: Patient Name: Order # 28343211 Insurance: None

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    UniqueEye Optique
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    This invoice from Jerome Kramer OD summarizes services provided to patient Sherry Dukacz on March 13, 2023. It includes charges for progressive plastic hi-index varilux comfort lenses for $650 with a $65 discount, and crizal sapphire UV lenses for $200 with a $20 discount, for a total of $850 and $85 in discounts. After insurance adjustments of $0 and copays of $0, the amount due from the patient is $765. A prior payment of $50 is noted, leaving a balance of $715.

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    This invoice from Jerome Kramer OD summarizes services provided to patient Sherry Dukacz on March 13, 2023. It includes charges for progressive plastic hi-index varilux comfort lenses for $650 with a $65 discount, and crizal sapphire UV lenses for $200 with a $20 discount, for a total of $850 and $85 in discounts. After insurance adjustments of $0 and copays of $0, the amount due from the patient is $765. A prior payment of $50 is noted, leaving a balance of $715.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    9 views1 page

    Invoice: Patient Name: Order # 28343211 Insurance: None

    Uploaded by

    UniqueEye Optique
    This invoice from Jerome Kramer OD summarizes services provided to patient Sherry Dukacz on March 13, 2023. It includes charges for progressive plastic hi-index varilux comfort lenses for $650 with a $65 discount, and crizal sapphire UV lenses for $200 with a $20 discount, for a total of $850 and $85 in discounts. After insurance adjustments of $0 and copays of $0, the amount due from the patient is $765. A prior payment of $50 is noted, leaving a balance of $715.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Invoice

    JEROME KRAMER OD FAAO


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

    Office # : 0045918
    Service Date: 03/13/2023
    Payment #: 37010320
    Patient Name: Sherry Dukacz Employee : 16
    881 Front St. Provider Name: Jerome Kramer
    Uniondale, NY 11553 NPI: 1437259637
    Item/ Service Description Proc Code Diagnosis Codes Retail Price Discount Insurance Allowance Insurance Copay Patient Due
    Patient Name: Sherry Dukacz
    Order # 28343211 Insurance: none

    Progressive Plastic Hi V2200,V2783, $650.00 $65.00 $585.00


    Index Varilux Comfort V2781
    1.67 - Clear
    Crizal Sapphire UV V2750 $200.00 $20.00 $180.00

    Total $850.00 $85.00 $0.00 $0.00 $765.00

    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
    3/13/2023 4:24:39 PM Sherry Dukacz $2473.00 Visa

    Payments Summary
    Total Due $765.00
    Total Payments Made ($50.00)
    Total Adjustments $0.00
    Balance $715.00

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