Good Faith Estimate

This information is provided to you as required by insurance in order that you do not have any surprise medical bills. Any testing fees will be discussed with you before the service is provided to you. RETINA PHOTOS ARE TAKEN FOR ALL NEW PATIENTS AND RETURNING PATIENTS ANNUALLY. Any fees charged to you when an insurance plan is in place are determined by the insurance company. D Vision Eyecare, LLC does not determine insurance coverage, co-pay, or deductible amount.

• Routine Vision Exam – Your cost can vary from $0 to $75
• Comprehensive Medical Eye Exam – Your cost can vary from $0 to $195
• Refraction – Your cost can vary from $0 to $42
• Retinal Photos – Your cost can vary from $0 to $39
• Anterior Photos – Your cost can vary from $0 to $25
• Visual Field – Your cost can vary from $0 to $40
• Dry Eye Testing – Your cost can vary from $0 to $50
• Myopia Management – Your cost can vary from $2100 to $2500
• Electro-retinogram – Your cost can vary from $0 to $160
• Punctal Plug placement – Your cost can vary from $0 to $250
• Zest Ocular Lid Treatment – Your cost is $295
• Other Services – Fees will be discussed prior to provision of service
• Eyeglass Frames – Your cost can vary from $0 to $600
• ​​​​​​​Eyeglass Lenses – Your cost can vary from $0 to $600

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises