Williams, Robert · MRN-000088 · Created Jun 11, 2026
| Item | Qty | Unit Price | Ins. Covered | Total |
|---|---|---|---|---|
Silhouette Momentum Full Rim FRAME · Silhouette | 1 | $320.00 | -$150.00 | $320.00 |
Hoya Nulux Progressive OD 1.67 LENS_OD · Hoya | 1 | $150.00 | -$75.00 | $150.00 |
Hoya Nulux Progressive OS 1.67 LENS_OS · Hoya | 1 | $150.00 | -$75.00 | $150.00 |
| Subtotal | $620.00 | |||
| Total | $620.00 | |||
| Insurance est. | -$300.00 | |||
| Patient Pays | $320.00 | |||
| Paid | -$160.00 | |||
| Balance Due | $160.00 | |||
Progressive HD design. CR39 Hi-Index 1.67.