Sample Dental Invoice
| Procedure / Description | ADA Code | Fee |
|---|---|---|
| Comprehensive oral evaluation | D0150 | $165.00 |
| Periodic oral prophylaxis (adult) | D1110 | $120.00 |
| Fluoride treatment (per arch) | D1206 | $55.00 |
| Bitewing X-ray (4 films) | D0274 | $85.00 |
| Composite filling (1 surface, posterior) | D2391 | $195.00 |
| Total Fee | $620.00 | |
| Insurance Payment (Delta Dental, 100%/80%/50%) | -$416.00 | |
| Patient Balance Due | $204.00 |
What to Include on a Dental Invoice
- Practice name, address, and phone
- Patient name, date of birth, and account number
- Date of service and provider name
- ADA procedure codes and descriptions
- UCR fee for each procedure
- Insurance member ID and group number
- Insurance allowed amount and payment
- Patient responsibility balance
- Total amount due and payment terms
Dental Insurance Basics for Billing
Most dental insurance plans use a 100/80/50 structure: 100% coverage for preventive care (cleanings, X-rays), 80% for basic procedures (fillings), and 50% for major procedures (crowns, root canals). Always verify benefits before treatment.
Show the UCR fee, the insurance allowable amount, and the patient balance as separate line items. Patients appreciate seeing exactly what their insurance covered and what they owe. Always include ADA codes — this makes it easy for patients to submit out-of-network claims.