Invoice Dentist in United States Los Angeles –Free Word Template Download with AI
1234 Wilshire Boulevard, Suite 500
Los Angeles, CA 90017
United States
Phone: (213) 555-0199
Email: [email protected]
License No: D-123456 (State of California)
Invoice Number: INV-2023-10-045
Date Issued: October 24, 2023
Due Date: November 24, 2023
Service Date: October 20, 2023
PENDING PAYMENTBill To:
Mr. Jonathan A. Sterling
789 Sunset Boulevard, Apt 4B
Los Angeles, CA 90028
United States
Phone: (323) 555-0142
Email: [email protected]
Insurance Information:
Provider: Delta Dental of California
Policy Holder: Jonathan A. Sterling
Policy Number: DD-CA-99887766
Group Number: GRP-554433
Subscriber ID: SUB-112233
| Code | Description of Dental Services | Unit Price | Qty | Amount |
|---|---|---|---|---|
| D0120 | Periodic Oral Evaluation - Comprehensive examination of the oral cavity and surrounding structures, including medical history review and risk assessment. | $150.00 | 1 | $150.00 |
| D0274 | Full Mouth Series of Radiographs - Complete set of X-rays to evaluate bone levels, tooth structure, and potential pathology not visible during clinical exam. | $250.00 | 1 | $250.00 |
| D1110 | Prophylaxis - Adult - Professional cleaning of teeth above and below the gumline to remove plaque, calculus, and stains. | $180.00 | 1 | $180.00 |
| D2391 | Direct Composite Resin Restoration - Class II (Buccal or Lingual Surface) - Tooth #19. Restoration of decay on the chewing surface and side of the lower left first molar. | $450.00 | 1 | $450.00 |
| D2392 | Direct Composite Resin Restoration - Class II (Buccal or Lingual Surface) - Tooth #30. Restoration of decay on the chewing surface and side of the lower right first molar. | $450.00 | 1 | $450.00 |
| D4341 | Periodontal Scaling and Root Planing - Quadrant - Deep cleaning procedure for the upper right quadrant to treat early-stage gum disease. | $350.00 | 1 | $350.00 |
| D9920 | Emergency Visit - Unscheduled visit for acute dental pain management and immediate treatment planning. | $100.00 | 1 | $100.00 |
| Subtotal: | $1,930.00 |
| Insurance Adjustment (Est.): | -$1,200.00 |
| Patient Responsibility: | $730.00 |
| Payment Received Today: | -$200.00 |
| TOTAL DUE: | $530.00 |
Payment Terms and Conditions:
This invoice represents the total cost of dental services rendered by SmileCare Dental Group in Los Angeles, California. Payment is due within 30 days of the invoice date. Please make checks payable to "SmileCare Dental Group" or pay online using the secure portal link provided in your patient email. Credit cards (Visa, MasterCard, Amex) are accepted with a 3% processing fee.
Insurance Notice: The amounts listed above are our standard fees. Insurance adjustments are estimates based on your plan's contracted rates. SmileCare Dental Group will submit claims directly to your insurance provider. You are responsible for any co-pays, deductibles, or non-covered services as outlined in your policy. Please verify your benefits with Delta Dental of California.
Late Fees: Accounts not paid within 30 days may be subject to a late fee of 1.5% per month. Accounts over 60 days past due may be referred to a collection agency, which could affect your credit score.
Questions? If you have any questions regarding this invoice or your treatment plan, please contact our billing department at (213) 555-0199 or email [email protected]. We are here to help you understand your dental investment.
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