Brightsmile Dental
Family & Cosmetic Dentistry
Statement
#BS-90142
Patient
Amara Johnson
Acct #2204 · DOB •/•/••
Date of service
May 29, 2025
Provider: Dr. Patel
Statement date
Jun 2, 2025
Due Jun 30
Procedure
Code
Fee
Periodic exam
D0120
$68.00
Bitewing radiographs (4)
D0274
$72.00
Adult prophylaxis
D1110
$118.00
Fluoride treatment
D1208
$38.00
Composite filling — 2 surface
D2392
$245.00
This statement reflects your estimated portion after insurance. Final amounts may adjust once your carrier processes the claim. Payment plans available — just ask the front desk.
Total charges
$541.00
Insurance estimate
– $372.00
Adjustments
$0.00
Patient balance
$169.00