CONCEPT #33 OF 100 · Medical, Dental & Clinical Practices · LAYOUT: three_tier_packages
Dental Implant & Prosthodontic Treatment Plan + Insurance Copay Breakdown
Standard / Reference: ADA CDT-2026 Procedure Codes · PPO Contracted Fee Schedule · Informed Financial Consent
Why professionals use this template: Dental treatment coordinators needing clear visual separation between gross CDT fees, PPO contracted write-offs, estimated insurance coverage, and phased patient copays.
144-DPI VECTOR PREVIEW · PAGE 1 OF 1
ACROFORM READY
Included Financial Metrics & Line-Item Schedule
Target Roles: General Dentists, Prosthodontists, Oral Surgeons & Orthodontic Practices · Search Keywords: dental treatment plan and patient financial agreement template pdf, cdt code dental implant estimate, dental insurance maximum and copay worksheet, phased restorative treatment plan
UCR STANDARD FEE TOTAL
$5,480.00
PPO CONTRACTED WRITE-OFF
-$1,090.00
ESTIMATED DELTA PPO BENEFIT
-$1,750.00
NET PATIENT PORTION (3 VISITS)
$2,640.00
| CODE | DESCRIPTION & TECHNICAL SPECIFICATION | BASIS / QTY | AMOUNT / DELTA |
|---|---|---|---|
| D6010 | Phase 1 (Visit 1): Surgical Placement of Endosteal Titanium Implant Body — Tooth #19 | PPO Allowed: $2,150 | $1,075.00 Copay |
| D7953 | Phase 1 (Visit 1): Bone Replacement Graft for Ridge Preservation at Implant Site | PPO Allowed: $540 | $270.00 Copay |
| D6057 | Phase 2 (Month 4): Custom CAD/CAM Titanium Milled Implant Abutment (Includes Torque) | PPO Allowed: $680 | $445.00 Copay |
| D6058 | Phase 2 (Month 4): Abutment-Supported Monolithic Zirconia Crown — Tooth #19 | PPO Allowed: $1,020 | $850.00 Copay |
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