Martinez, Carlos · MRN-000078 · Created Jun 15, 2026
| Item | Qty | Unit Price | Ins. Covered | Total |
|---|---|---|---|---|
Bausch + Lomb Ultra Toric 6pk OD CL_BOX_OD · B+L | 3 | $30.00 | -$50.00 | $90.00 |
Bausch + Lomb Ultra Toric 6pk OS CL_BOX_OS · B+L | 3 | $30.00 | -$50.00 | $90.00 |
| Subtotal | $180.00 | |||
| Total | $180.00 | |||
| Insurance est. | -$100.00 | |||
| Patient Pays | $80.00 | |||
| Paid | -$0.00 | |||
| Balance Due | $80.00 | |||
No lab information recorded.
Notes
Prior auth pending with Aetna. Hold until auth received.