DR JJ SERFONTEIN
20 KLOOF STREET
ROZENHOF COURT
CAPE TOWN, 8001
Telephone : 0214245172
Fax :
Practice Number : 0178446
TREATMENT ESTIMATE
26-10-2016
08:39
ESTIMATION
Tel No :
Med Aid no :
Medical Aid :
Account no :
151
Tooth #
Tooth
Med Aid
Patient
Code
Description
Surf/Quad
Fee
Amt
Amount
Treatment Plan 1
Record taking and DSD
8104
Limited oral examination
K02.9
270.00
0.00
270.00
8109
Infection control/barrier tech
Z01.2
30.00
0.00
30.00
8109
Infection control/barrier tech
Z01.2
30.00
0.00
30.00
8117
Diagnostic models
K02.9
515.00
0.00
515.00
8119
Diagnostic models mounted
327.00
0.00
327.00
8121
Oral/facial images
K02.9
120.00
0.00
120.00
8115
Panoramic film
Z01.2
555.00
0.00
555.00
8099
Dental laboratory service
Z46.3
1050.00
0.00
1050.00
Sub Totals:
2897.00
0.00
2897.00
Prep Veneers
8109
Infection control/barrier tech
Z01.2
30.00
0.00
30.00
8109
Infection control/barrier tech
Z01.2
30.00
0.00
30.00
8145
Local anaesthesia
K02.9
92.00
0.00
92.00
8110
Sterilized instrumentation
Z01.2
190.00
0.00
190.00
8109
Infection control/barrier tech
Z01.2
30.00
0.00
30.00
8109
Infection control/barrier tech
Z01.2
30.00
0.00
30.00
8145
Local anaesthesia
K02.9
92.00
0.00
92.00
8110
Sterilized instrumentation
Z01.2
190.00
0.00
190.00
Sub Totals:
684.00
0.00
684.00
Fit Veneers
8109
Infection control/barrier tech
Z01.2
30.00
0.00
30.00
8109
Infection control/barrier tech
Z01.2
30.00
0.00
30.00
8145
Local anaesthesia
K02.9
92.00
0.00
92.00
8110
Sterilized instrumentation
Z01.2
190.00
0.00
190.00
8374
Inlay/onlay porcelain 4+ surf
K02.9
16
MODB
5100.00
0.00
5100.00
8374
Inlay/onlay porcelain 4+ surf
K02.9
15
MODB
5100.00
0.00
5100.00
8374
Inlay/onlay porcelain 4+ surf
K02.9
14
MODB
5100.00
0.00
5100.00
8552
Veneer porcelain lab
K02.9
13
IB
4100.00
0.00
4100.00
8552
Veneer porcelain lab
K02.9
12
IB
4100.00
0.00
4100.00
8552
Veneer porcelain lab
K02.9
11
IB
4100.00
0.00
4100.00
8552
Veneer porcelain lab
K02.9
21
IB
4100.00
0.00
4100.00
8552
Veneer porcelain lab
K02.9
22
IB
4100.00
0.00
4100.00
8552
Veneer porcelain lab
K02.9
23
IB
4100.00
0.00
4100.00
8374
Inlay/onlay porcelain 4+ surf
K02.9
25
MODB
5100.00
0.00
5100.00
8374
Inlay/onlay porcelain 4+ surf
K02.9
24
MODB
5100.00
0.00
5100.00
8374
Inlay/onlay porcelain 4+ surf
K02.9
26
MODB
5100.00
0.00
5100.00
8374
Inlay/onlay porcelain 4+ surf
K02.9
46
MODB
5100.00
0.00
5100.00
8374
Inlay/onlay porcelain 4+ surf
K02.9
45
MODB
5100.00
0.00
5100.00
8374
Inlay/onlay porcelain 4+ surf
K02.9
44
MODB
5100.00
0.00
5100.00
8552
Veneer porcelain lab
K02.9
43
IB
4100.00
0.00
4100.00
8552
Veneer porcelain lab
K02.9
42
IB
4100.00
0.00
4100.00
8552
Veneer porcelain lab
K02.9
41
IB
4100.00
0.00
4100.00
8552
Veneer porcelain lab
K02.9
31
IB
4100.00
0.00
4100.00
8552
Veneer porcelain lab
K02.9
32
IB
4100.00
0.00
4100.00
8552
Veneer porcelain lab
K02.9
33
IB
4100.00
0.00
4100.00
8374
Inlay/onlay porcelain 4+ surf
K02.9
34
MODB
5100.00
0.00
5100.00
8374
Inlay/onlay porcelain 4+ surf
K02.9
35
MODB
5100.00
0.00
5100.00
8374
Inlay/onlay porcelain 4+ surf
K02.9
36
MODB
5100.00
0.00
5100.00
Page 1
DR JJ SERFONTEIN
20 KLOOF STREET
ROZENHOF COURT
CAPE TOWN, 8001
Telephone : 0214245172
Fax :
Practice Number : 0178446
TREATMENT ESTIMATE
26-10-2016
08:39
Patient : ESTIMATION
Tel No:
Med Aid no :
Medical Aid:
Account no: 151
Tooth #
Tooth
Med Aid
Patient
Code
Description
Surf/Quad
Fee
Amt
Amount
8099
Dental laboratory service
Z46.3
50400.00
0.00
50400.00
Sub Total1:61142.00
0.00161142.00
Totals:
164723.00
0.00164723.00
Tooth Chart
18
28
8
7
6
5
4
3
2
1
1
2
3
4
5
6
7
8
48
38
Page 2