병원 영수증

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라이브 미리보기

07/31/2026

Proposal Treatment

Dr. John Doe

123 Main St, Anytown, USA

MAURA

123 Main St, Anytown, USA

ID : AF54hh

단계날짜 계획appt공급자서비스Tth서핑요금안내가볍게 두드리기
1D20260731D20260731DJOComprehensive ORAL EVALUSA 16$200$50$20
소계$0.00$0.00$0.00
$0.00

Insurance Coverage is only an estimation. A guarantor is responsible for all treatment not covered by insurance. The Above prices are valid for 60 days.

총 제안

$0.00

완성 된 총

$5000

합격

$5000

제안 된 보험

$0.00

I have been advised of the treatment recommendation above, I am aware delaying treatment may lead to more extensive and costly treatment. A new exam may be required after 60 days

환자 또는 보호자의 서명________________________________________날짜

Current Dental Terminology(CDT) © American Dental Association(ADA). All Rights Reserved

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