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Treatment Plan
- Subject: Treatment Plan
- From: http://www.gmail.com/~drtakeuchidds
- Date: Thu, 20 Nov 2025 18:19:54 -0500
Hello Robert,
I have attached your estimate for your upcoming filling appointment.
Office of Doug Takeuchi, DDS
189 N Bascom Ave Ste 110
where-I-live 95128
(408) 295-5651
Content-Type: application/pdf; name="TreatmentPlan.pdf"
Content-Disposition: attachment; filename="TreatmentPlan.pdf"
Content-Transfer-Encoding: base64
X-Attachment-Id: d872381e8022cae_0.1
Fillings
Doug Takeuchi DDS
(408)295-5651
Robert Brown (1), DOB 04/01/1965
11/20/2025
Surf
ODL
Code
D2393
2
OD
D2392
5
Referred Out
Treatment Planned
Sub
Description
X
resin-based composite - three
surfaces, posterior
Pri Deduct Applied: $75.00
X
resin-based composite - two surfaces,
posterior
Subtotal
Total
Fee
Allowed Pri Ins Sec Ins
305.00
0.00 161.00
0.00
Pat
144.00
275.00
0.00
192.50
0.00
82.50
580.00
0.00
353.50
0.00
226.50
Family Insurance Benefits
BenefitName
Family Maximum
Family Deductible
Primary
Secondary
Individual Insurance Benefits
BenefitName
Annual Maximum
Deductible
Deductible Remaining
Insurance Used
Pending
Remaining
Primary
Secondary
2000.00
75.00
170.00
0.00
1830.00
If you have dental insurance, please be aware that THIS IS AN ESTIMATE ONLY.
Coverage may be different if your deductible has not
been met, annual maximum has been met, or if your coverage table is lower than
average. These fees will be honored for 90 days.
Signature