Smith, Jennifer · MRN-000055 · Created Jun 18, 2026
| Item | Qty | Unit Price | Ins. Covered | Total |
|---|---|---|---|---|
Lindberg Air Titanium Rim FRAME · Lindberg | 1 | $285.00 | -$100.00 | $285.00 |
Transitions Gen 8 Progressive OD LENS_OD · Essilor | 1 | $125.00 | -$25.00 | $125.00 |
Transitions Gen 8 Progressive OS LENS_OS · Essilor | 1 | $125.00 | -$25.00 | $125.00 |
| Subtotal | $535.00 | |||
| Discount | -$50.00 | |||
| Total | $485.00 | |||
| Insurance est. | -$150.00 | |||
| Patient Pays | $335.00 | |||
| Paid | -$200.00 | |||
| Balance Due | $135.00 | |||
Anti-reflective coating, photochromic lens. Frame PD OD 32mm, OS 31mm. Seg height 18mm.
Notes
Patient requested photochromic transitions. Verified PD before sending.