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Pawtucket
Plastic Surgery |
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| 1141 Shawnee Run
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| Pawtucket, RI 02861
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| Phone:(800 555-2435 |
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| Patient Coordinator: Angie Sparks
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| Treatment Proposal
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| Date - 8/19/2005
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| Goldberg, Jerry V - 713
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| 256 Seasaw St.
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| Pawtucket, RI 02860
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The fees that are indicated are for the procedures listed below. These fees will be honored for one year from today's date. All fees are payable two weeks prior to the scheduled date of the procedure. Fees may be paid by cash, check, Visa, MasterCard or Discover. |
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Practice Fees
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Outside Fees |
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% Discount |
Total Discounts |
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| Liposuction 3 Areas, Liposuction 3 Areas, Liposuction 3 Areas |
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Procedure Fees |
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INJECTION, INTRALESIONAL; UP TO & INCL 7 LESIONS |
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$83.43 |
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$0.00 |
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LAYER CLOSURE, WOUNDS, NECK, HANDS, FEET &/OR EXT GENITALIA; 2.6 TO 7.5 CM |
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$428.39 |
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$0.00 |
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10.00% |
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$40.30 |
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EXCISION, MALIGNANT LESION, INCL MARGINS, FACE/EARS/EYELIDS/NOSE/LIPS/MUCO; EXCISED DIAM > 4.0 CM |
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$59.92 |
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$0.00 |
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Product Fees |
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Extra Rich Moisturizer |
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$25.75 |
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$0.00 |
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Anesthesia Fees |
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Anesthesia |
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$222.25 |
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$4.75 |
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5.00% |
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$11.35 |
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Facility Fees |
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Facility Fee |
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$93.00 |
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$10.00 |
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Procedure Fees: |
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$571.74 |
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$0.00 |
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Product Fees: |
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$25.75 |
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$0.00 |
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Anesthesia Fees: |
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$222.25 |
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$4.75 |
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Facility Fees: |
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$93.00 |
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$10.00 |
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Discounts: |
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($51.65) |
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Totals: |
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$861.09 |
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$14.75 |
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| Total Fees Payable To Practice:
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| $557.19
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| Total Anesthesia Fees Payable To
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| Pawtucket Anesthesia
Center: $215.65
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| Total Facility Fees Payable To
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| Pawtucket Surgery
Center: $103.00
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| Total Cost of Surgery: $875.80 |
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Procedures are scheduled at least two to three months in advance. Please call at your earliest convenience to reserve a time. |
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Patient's Signature _____________________________________________________ Date__________________ |
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Witness Signature _____________________________________________________ Date__________________ |
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