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Treatment Plan
Case Type
Treatment Plan
Select procedures · adjust fee & quantity
Provider
Schedule
Office full fee · per-line edits override
Selected Procedures 0
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Patient Summary
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Financial Summary
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Treatment Total
Standard office fee
$0.00
Insurance Contribution
$
Δ Limit
$
− $0.00
Discount / Promo
$
Patient Total
After insurance — standard rate
$0.00
Your Balance
Payment options below
$0.00
Payment Options
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Payment in Full
In-Office Payment Plan · 1.5% management fee
* 3% courtesy credit applied for Zelle, cash, or check paid in full. Standard rate for card. In-office plans include 1.5% management fee; post-dated checks or auto-pay required.
Clinical Notes
Prints as a separate page if shown
Important Notice: All fees are estimates and subject to change based on actual clinical findings. Insurance benefits are estimates only; actual payment depends on individual plan coverage, annual maximums, waiting periods, and frequency limitations. The patient is ultimately responsible for all charges not covered by insurance. A 3% courtesy credit is applied when paying the full balance by Zelle, cash, or check at time of service. In-office payment plans include a 1.5% management fee.