EFTA01197069.pdf

Aug.10.2015 03:43 PM PAGE. 1/ 2 Teo,r %c.110, -nce,r-)A r \)O4si EFTA01197069  Aug.10.2015 03:43 PM PAGE. 2/ 2 Patient: Chart Data: 8/10/2015 Provider: Chart ai 004082 SS*: 062-78-3227 Birthdate: 10/30/1953 CD CD CD CD CD D Q9 D OD (19) qP A @ (9) I coco9g A I! , ic00as) 000g0"Dg0 I (ipt er, cs .8 A s (2:?), A Il Treatment Plan • Completed II Conditions Existing-This Prov Existing-Other Prov Treatment Plaii Estimate Tooth Surface Code Prov Description Amount Pat Prim Ins 23 04265 0082 Bio mat, sft&osseous tiss regen 650.00 130.00 520.00 27 05862 DDS2 Precision attachment, B/R 990.00 495.00 495.00 23 06010 DDS2 Surg place implant: endosteal 2,800.00 1,400.00 1,400.00 28 06010 0052 Surg place.implant: endosteal 2,800.00 1,400.00 1,400.00 LO 05860 DDS2 Overdenture-complete. B/R 2,550.00 1,275.00 1,275.00 23 05862 DDS2 Precision attachment, B/R 990.00 495.00 495.00 26 D5862 DDS2 Precision attachment, B/R 990.00 495.00 495.00 22 D5862 DDS2 Precision attachment, B/R 990.00 495.00 495.00 23 06104 DDS2 Bone Graft, Implant Placement 550.00 275.00 275.00 22 D6010 DDS2 Surg place implant: endosteal 2,800.00 1,400.00 1,400.00 27 D6010 DDS2 Surg place implant: endosteal 2,800.00 1,400.00 1,400.00 4 02740 DDS2 Crown-porcelain/ceramic substr 1.950.00 975.00 975.00 5 D2740 DDS2 Crown-porcelain/ceramic substr 1,950.00 975.00 975.00 6 02740 DDS2 Crown-porcelain/ceramic substr 1,950.00 975.00 975.00 7 D2740 DDS2 Crown-porcelain/ceramic substr 1,950.00 975.00 975.00 8 D2740 DDS2 Crown-porcelain/ceramic substr 1,950.00 975.00 975.00 9 02740 DDS2 Crown-porcelain/ceramic substr 1,950 00 975.00 975.00 10 02740 DDS2 Crown-porcelain/ceramic substr 1,950.00 975.00 975.00 11 D2740 D032 Crown-porcelain/ceramic substr 1,950.00 975.00 975.00 2'15 D5213 DDS2 Maxil partial-metal Base Wads 2,275 00 1,137.50 1,137.50 Treatment Plan Totals: 36,785.00 18,197.50 18,587.50 Treatment Plans Are Estimates Only Ut.=tipper Left liRaUpper Right LLaLower Left LRaLower Righ Vell --th11 mcctaauf pagsd - &S t itt( pugsboniii 6,33 utak\ aka MStkialk. OU4 PAktek Z bl bOb Page: 1 of 1 EFTA01197070