Invoice Dentist in United States New York City –Free Word Template Download with AI
123 West 57th Street, Suite 400
New York, NY 10019
United States
Phone: (212) 555-0199 | Fax: (212) 555-0198
Email: [email protected]
NPI: 1234567890 | NY State License: #123456
Invoice #: INV-2023-10-045
Date: October 24, 2023
Due Date: November 24, 2023
Provider: Dr. Sarah Jenkins, DDS
Bill To:
Mr. James Anderson
456 Park Avenue South
Apt 7B
New York, NY 10016
United States
Phone: (646) 555-0123
Patient DOB: 05/12/1985
Insurance Information:
Primary Payer: Empire BlueCross BlueShield
Group #: NY-GRP-998877
Policy #: P-123456789
Subscriber: James Anderson
Relationship: Self
Claim Status: Pending Adjudication
| Date of Service | CDT Code | Description of Dental Services | Fee Schedule | Insurance Est. | Patient Resp. |
|---|---|---|---|---|---|
| 10/24/2023 | D0120 | Periodic oral evaluation - Established patient comprehensive exam including review of medical history. | $150.00 | $150.00 | $0.00 |
| 10/24/2023 | D0274 | Full mouth series of radiographs - Comprehensive diagnostic imaging required for treatment planning. | $350.00 | $350.00 | $0.00 |
| 10/24/2023 | D1110 | Prophylaxis - Adult preventive cleaning including scaling and polishing to remove plaque and calculus. | $200.00 | $200.00 | $0.00 |
| 10/24/2023 | D2391 | Direct posterior composite resin restoration - Tooth #19 (Lower Left First Molar). Moderate size cavity. | $450.00 | $315.00 | $135.00 |
| 10/24/2023 | D2392 | Direct posterior composite resin restoration - Tooth #30 (Lower Right First Molar). Extensive size cavity. | $550.00 | $385.00 | $165.00 |
| 10/24/2023 | D4341 | Periodontal scaling and root planing - Quadrant 3 (Lower Left). Deep cleaning for gum disease treatment. | $300.00 | $210.00 | $90.00 |
| 10/24/2023 | D9110 | Anesthesia - Local infiltration. Administration of local anesthetic for pain control during procedures. | $50.00 | $50.00 | $0.00 |
| Total Procedure Fees: | $2,050.00 |
| Less Insurance Allowance: | -$1,660.00 |
| Less Previous Payments: | $0.00 |
| Total Amount Due: | $390.00 |
Payment Terms and Important Information:
This invoice represents the financial responsibility for dental services rendered at our New York City practice. Please note that the "Patient Responsibility" column reflects the estimated co-pay, deductible, or non-covered services based on your current insurance benefits with Empire BlueCross BlueShield. Final amounts may vary slightly upon official claim adjudication by the insurance carrier.
Payment Methods: We accept Visa, MasterCard, American Express, Discover, Cash, and Personal Checks. For electronic payments, please visit our secure portal at www.manhattanelitedental.com/pay.
New York State Regulations: In accordance with New York State Dental Society guidelines and NYC consumer protection laws, a detailed treatment plan was provided and signed prior to the commencement of restorative and periodontal therapy. Failure to pay the outstanding balance by the due date may result in a late fee of 1.5% per month or the minimum amount permitted by law. Accounts remaining unpaid for more than 60 days may be referred to a collection agency, which could impact your credit score.
If you have any questions regarding this invoice, your insurance benefits, or the specific dental procedures performed, please contact our billing department at (212) 555-0199 between the hours of 9:00 AM and 5:00 PM, Monday through Friday.
Authorized Provider Signature:Dr. Sarah Jenkins, DDS
Manhattan Elite Dental Care Patient/Guarantor Signature:
____________________________
Date: _______________________ ⬇️ Download as DOCX Edit online as DOCX
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