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Treatment Plan
Patient: Sarah Jenkins (ID: PT-8942) • Date: Sep 15, 2026
| Procedure Name | CDT Code | Fee |
|---|---|---|
| Resin-based composite - one surface, posterior | D2391 | $145.00 |
| Periodic oral evaluation - established patient | D0120 | $55.00 |
| Bitewings - two radiographic images | D0272 | $30.00 |
Financial Summary
Gross Fee$230.00
Insurance Portion-$145.00
Out-of-Pocket$85.00
Total Plan Value: $230.00
Estimate based on patient's current active insurance policy (Delta Dental PPO). Final out-of-pocket costs may vary based on deductibles and maximums.