Invoice Dentist in United States Chicago –Free Word Template Download with AI
123 Michigan Avenue, Suite 400
Chicago, Illinois 60601
United States
Phone: (312) 555-0199
Email: [email protected]
NPI: 1234567890 | DEOIS License: 123-456789
Invoice Number: INV-CHI-2023-8942
Date Issued: October 24, 2023
Due Date: November 24, 2023
Service Date: October 20, 2023
Bill To (Patient)Mr. John A. Doe
456 Lake Shore Drive
Chicago, IL 60611
United States
Phone: (773) 555-0123
DOB: 05/15/1985
Insurance InformationProvider: Blue Cross Blue Shield of Illinois
Policy Number: BCBS-IL-99887766
Group Number: GRP-CHI-5544
Subscriber ID: SUB-12345
| Code | Description of Dental Services | Teeth | Fee | Adj. | Balance |
|---|---|---|---|---|---|
| D0120 | Periodic Oral Evaluation - Comprehensive examination of the oral cavity and surrounding structures, including medical history review. | - | $120.00 | -$40.00 | $80.00 |
| D0274 | Full Mouth Series of Radiographs - Complete set of X-rays to assess bone levels, root health, and detect hidden decay. | - | $250.00 | -$75.00 | $175.00 |
| D1110 | Prophylaxis - Adult dental cleaning to remove plaque, calculus, and stains from above and below the gumline. | - | $150.00 | -$50.00 | $100.00 |
| D2391 | Amalgam Restoration - Two surfaces, posterior tooth. Filling procedure to restore structural integrity. | #30 | $180.00 | -$60.00 | $120.00 |
| D2750 | Resin-Based Composite - Two surfaces, posterior tooth. Tooth-colored filling for aesthetic restoration. | #14 | $220.00 | -$70.00 | $150.00 |
| D4341 | Periodontal Scaling and Root Planing - Deep cleaning procedure for four or more teeth to treat gum disease. | Q1 | $450.00 | -$135.00 | $315.00 |
| D9110 | Anesthesia - Local infiltration. Administration of anesthetic to ensure patient comfort during procedures. | - | $50.00 | $0.00 | $50.00 |
| Subtotal (Total Fees): | $1,420.00 |
| Insurance Adjustment: | -$430.00 |
| Insurance Payment (EOB #998877): | -$650.00 |
| Previous Payments: | $0.00 |
| Patient Responsibility: | $340.00 |
This invoice represents the financial responsibility of the patient for dental services rendered at our Chicago, Illinois facility. Payment is due within 30 days of the invoice date. Late payments may be subject to a 1.5% monthly finance charge. We accept cash, checks, major credit cards (Visa, MasterCard, Amex), and HSA/FSA cards. Please make checks payable to "Windy City Dental Group." If you have questions regarding this invoice or your insurance benefits, please contact our billing department at (312) 555-0199. Authorized By
Dr. Sarah Jenkins, DDS
Lead Dentist
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