Cash Pay Invoice
1515 River Park Drive, Suite 100 • Sacramento, CA 95815 • 916-649-1515
Date
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Month
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Day
Year
Name
Date of Birth
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Month
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MRN
Categories:
All
All
Office Visits
Testing
Office Procedures
Lasers
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Office Visits
New Patient Consultation
Cataract, Cornea or Glaucoma Consultation
$
400
New Patient Consultation
Pterygium Consultation
$
200
New Patient Optometrist Consultation
$
125
Existing Patient Comprehensive Exam
$
125
Brief Exam
$
75
Refractive Surgery Consultation
Consultation for LASIK or PRK
$
100
Refractive Lens Exchange Consultation
$
400
Testing
A-Scan
$
125
Corneal Topography
$
100
Endothelial Count
$
100
Fundus Photography
$
100
Gonio
$
40
OCT
$
100
Pachymetry
$
40
Pentacam
$
100
Refraction
$
50
Slit Lamp Photos
$
40
Visual Field
$
100
Office Procedures
AM Graft/Prokera
$
1,430
Blephex
$
300
Per Treatment(s)
Chalazion
One Location
$
215
Chalazion
Multiple Locations
$
265
Chelation EDTA
$
500
Conjunctival Biopsy
$
230
Conjunctival Excision < 1 cm
$
305
Conjunctival Excision > 1 cm
$
420
Conjunctivoplasty
$
215
Corneal Cultures (scraping)
$
150
Each
Durysta
$
2,500
Epilation Ellman
$
170
Per eye(s)
Epilation Forceps
$
45
Per eye(s)
Eyelid Biopsy
$
230
Each
Punctal Plug
$
150
Per insertion
Punctual Cautery/Snip
$
150
Per eye(s)
Punctual Irrigation
$
170
Per eye(s)
Removal of Foreign Body
$
100
Per eye(s)
SK (Superficial Keratectomy)
$
880
Tarsorrhaphy
Permanent
$
600
Per eye(s)
Tarsorrhaphy
Temporary
$
230
Per eye(s)
Lasers
SLT
$
500
Per eye(s)
YAG Capsulotomy
$
430
Per eye(s)
YAG Iridotomy
$
450
Per eye(s)
Total Amount Due
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