DR JJ SERFONTEIN
20 KLOOF STREET
ROZENHOF COURT
CAPE TOWN, 8001
Telephone : 0214245172
Fax :
Practice Number : 0178446
TREATMENT ESTIMATE
26-10-2016
08:37
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 2
IMPLANT PLACEMENT
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
9008
Alv ridge augm 1 to 2 teeth
K08.1
15
2950.00
0.00
2950.00
9183
Surg plce endost implnt 1st
K08.1
15
3260.00
0.00
3260.00
9187
Cost of endosteal implant body
K08.1
15
8400.00
0.00
8400.00
Treatment Notes:
RN Strauman SL Active TiZr, NTP
RN Closure cap
9010
Sinus lift procedure
K08.1
15
2439.00
0.00
2439.00
Treatment Notes:
8107
Intraoral periapical film
Z01.2
165.00
0.00
165.00
Treatment Notes:
8107
Intraoral periapical film
Z01.2
165.00
0.00
165.00
Treatment Notes:
8107
Intraoral periapical film
Z01.2
165.00
0.00
165.00
Treatment Notes:
8107
Intraoral periapical film
Z01.2
165.00
0.00
165.00
Treatment Notes:
8107
Intraoral periapical film
Z01.2
165.00
0.00
165.00
Treatment Notes:
8110
Sterilized instrumentation
Z01.2
190.00
0.00
190.00
Treatment Notes:
8220
Cost of suture material
K09.9
270.00
0.00
270.00
Treatment Notes:
Sub Totals:18486.00
0.00
18486.00
EXPOSURE
Appointment Notes:
8109
Infection control/barrier tech
Z01.2
30.00
0.00
30.00
Treatment Notes:
8109
Infection control/barrier tech
Z01.2
30.00
0.00
30.00
Treatment Notes:
8145
Local anaesthesia
K02.9
92.00
0.00
92.00
Treatment Notes:
9190
Surg plce endost abut 1st
K08.1
15
730.00
0.00
730.00
Treatment Notes:
9188
Cost of prefabricated abutment
K08.1
15
650.00
0.00
650.00
Treatment Notes:
8220
Cost of suture material
K09.9
270.00
0.00
270.00
Treatment Notes:
8107
Intraoral periapical film
Z01.2
165.00
0.00
165.00
Treatment Notes:
Sub Totals: 1967.00
0.00
1967.00
IMPRESSIONS
Appointment Notes:
8109
Infection control/barrier tech
Z01.2
30.00
0.00
30.00
Treatment Notes:
8109
Infection control/barrier tech
Z01.2
30.00
0.00
30.00
Treatment Notes:
Page 1
DR JJ SERFONTEIN
20 KLOOF STREET
ROZENHOF COURT
CAPE TOWN, 8001
Telephone : 0214245172
Fax :
Practice Number : 0178446
TREATMENT ESTIMATE
26-10-2016
08:37
Patient : ESTIMATION
Tel No:
Med Aid no :
Medical Aid:
Account no: 151
Tooth #
Tooth
Med Aid
Patient
Code
Description
Surf/Quad
Fee
Amt
Amount
8145
Local anaesthesia
K02.9
92.00
0.00
92.00
Treatment Notes:
8107
Intraoral periapical film
Z01.2
165.00
0.00
165.00
Treatment Notes:
Sub Totals:
317.00
0.00
317.00
IMPLANT CROWN
Appointment Notes:
8109
Infection control/barrier tech
Z01.2
30.00
0.00
30.00
Treatment Notes:
8109
Infection control/barrier tech
Z01.2
30.00
0.00
30.00
Treatment Notes:
8145
Local anaesthesia
K02.9
92.00
0.00
92.00
Treatment Notes:
8537
Crown impl sup porc w/mtl
K08.1
15
6200.00
0.00
6200.00
Treatment Notes:
8099
Dental laboratory service
Z46.3
3900.00
0.00
3900.00
Treatment Notes:
8600
Cost of implant components
K08.1
2800.00
0.00
2800.00
Treatment Notes:
8107
Intraoral periapical film
Z01.2
165.00
0.00
165.00
Treatment Notes:
Sub Totals:13217.00
0.00
13217.00
Totals:
33987.00
0.00
33987.00
Tooth Chart
18
28
8
7
6
5
4
3
2
1
1
2
3
4
5
6
7
8
48
38
Page 2