Invoice Orthodontist in United States San Francisco –Free Word Template Download with AI
Dr. Elena Rodriguez, DDS, MS
Board Certified Orthodontist
1234 California Street, Suite 400
San Francisco, CA 94108
United States
Phone: (415) 555-0199
Email: [email protected]
Invoice Number: INV-SF-2023-8942
Date Issued: October 24, 2023
Due Date: November 24, 2023
Payment Status: Pending
Bill To:
Mr. Jonathan Miller
456 Market Street, Apt 12B
San Francisco, CA 94105
United States
Phone: (415) 555-0876
Insurance / Pay From:
Blue Shield of California
Policy Holder: Jonathan Miller
Member ID: BS-99887766
Group Number: SF-GRP-4421
Provider ID: CA-ORTH-5512
| # | Description of Orthodontic Services | CPT Code | Quantity | Unit Price | Total |
|---|---|---|---|---|---|
| 1 |
Initial Orthodontic Consultation & Diagnostic Records Comprehensive examination of the patient's dentition, facial structure, and occlusion. Includes panoramic radiograph, cephalometric X-ray, and digital intraoral photographs. This initial assessment is critical for determining the necessity of orthodontic intervention and formulating a precise treatment plan tailored to the patient's specific anatomical needs within the standards of care practiced in San Francisco. |
D0150 | 1 | $350.00 | $350.00 |
| 2 |
Orthodontic Treatment with Fixed Appliances (Braces) Placement of comprehensive fixed orthodontic appliances (brackets and archwires) on both the maxillary and mandibular arches. This procedure involves the bonding of ceramic brackets to the teeth and the insertion of initial archwires to begin the process of alignment and leveling. This service represents the core of the orthodontic treatment plan designed to correct malocclusion and improve dental aesthetics. |
D8050 | 1 | $6,500.00 | $6,500.00 |
| 3 |
Periodic Orthodontic Adjustment & Progress Evaluation Routine adjustment of fixed orthodontic appliances. Includes examination of tooth movement, replacement of archwires, adjustment of ligatures, and assessment of treatment progress. This visit ensures that the teeth are moving according to the planned trajectory and allows the orthodontist to make necessary modifications to the force applied to the teeth. |
D8060 | 4 | $150.00 | $600.00 |
| 4 |
Interproximal Reduction (IPR) Selective enamel stripping to create space for tooth alignment. This minimally invasive procedure is performed to resolve minor crowding and optimize the final position of the teeth without the need for extractions. It is a common adjunctive procedure in modern orthodontics to achieve ideal contact points and arch form. |
D4346 | 1 | $200.00 | $200.00 |
| 5 |
Removable Retainer (Hawley Type) Fabrication and delivery of a custom-fitted removable retainer for the maxillary arch. This device is essential for maintaining the corrected position of the teeth following the active phase of orthodontic treatment. Proper use of the retainer is crucial to prevent relapse and ensure the long-term stability of the orthodontic results. |
D0276 | 1 | $300.00 | $300.00 |
| Subtotal: | $7,950.00 |
| Insurance Adjustment (Blue Shield): | -$3,500.00 |
| Insurance Payment Applied: | -$3,500.00 |
| Patient Responsibility (Due): | $950.00 |
Payment Terms & Important Information
This invoice reflects the charges for orthodontic services rendered by Pacific Heights Orthodontics, located in San Francisco, California. As a premier orthodontic practice in the United States, we are committed to providing transparent billing and exceptional patient care.
Payment Methods: We accept major credit cards (Visa, MasterCard, American Express), checks payable to "Pacific Heights Orthodontics," and direct bank transfers. For your convenience, we also offer flexible financing plans through CareCredit for patients residing in San Francisco and the surrounding Bay Area.
Insurance Claims: We have submitted the necessary claims to your insurance provider, Blue Shield of California. The amounts listed as "Insurance Adjustment" and "Insurance Payment Applied" are based on the Explanation of Benefits (EOB) received. Please review your EOB carefully. If you have any questions regarding your coverage or the amounts billed, please contact our billing department at (415) 555-0199.
Due Date: The remaining balance of $950.00 is due by November 24, 2023. Late payments may be subject to a 1.5% monthly finance charge as per California state regulations. Please ensure timely payment to avoid any interruption in your orthodontic treatment.
Questions? If you have any questions about this invoice, your treatment plan, or your insurance benefits, please do not hesitate to contact us. Our staff is here to assist you in navigating the financial aspects of your orthodontic care.
Authorized SignatureDr. Elena Rodriguez, DDS, MS Patient/Guardian Signature
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
Create your own Word template with our GoGPT AI prompt:
GoGPT