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Smile Dental Clinic
123 Oral Health Plaza, Suite 400 Beverly Hills, CA 90210 (310) 555-0198 [email protected] NPI: 1234567890
Receipt #: INV-2026-8842
3/20/2026 2:30:00 PM
1
Comprehensive Oral Exam (D0150)
$85.00
1
Full Mouth X-Rays (D0210)
$145.00
1
Prophylaxis - Adult (D1110)
$95.00
1
Composite-2 Surf, Post (D2392) - Tooth #30 MO
$210.00
Subtotal
$535.00
Insurance Est. Coverage
$-350.00
Total
$185.00
THANK YOU FOR TRUSTING US WITH YOUR SMILE! Please follow all post-treatment care instructions. Failure to provide 24-hour notice for cancellations may result in a fee. All insurance claims are submitted as a courtesy.