Patient summary
Your dental benefits
at a glance
Everything below reflects what your plan reported for today's visit. Amounts are estimates from this office's fees — not a bill. Your final cost is set once the claim is processed.
Benefits — In NetworkBenefit details
Maximums & Deductibles
Annual max remaining
$1,140.00
of $1,500.00 · used $360.00
Deductible (individual)
$0.00
of $50.00 · met $50.00
Deductible (family) met
$50.00
of $150.00 · remaining $100.00
Out-of-pocket max
$3,500.00
Member out-of-pocket ceiling · remaining $3,190.00
Annual max (family)
$2,640.00
of $3,000.00 · used $360.00
Deductible waived for: Preventive
Classifications
Preventive
100%
no deductible
Basic / Restorative
80%
deductible applies
Major
50%
deductible applies · waiting period 6 mo
Periodontal
80%
deductible applies
Endodontic
80%
deductible applies
Oral Surgery
80%
deductible applies
Orthodontics
50%
deductible applies · waiting period 12 mo
Implants
50%
deductible applies · waiting period 6 mo
Today's visit
Molar RCT, CBCT — Limited Field of View, Periapical — First Film, Limited Oral Evaluation have an estimated patient share of $742.00.
Any treatment beyond this visit is estimated on the following pages, procedure by procedure.
Plan & policy detail
L. Anderson · Summit Dental Plan
Patient
Name:L. Anderson
DOB:04/11/1988
Relationship:Self
Appointment:08/20/2026
Subscriber
Name:L. Anderson
Member ID:SAMPLE-SDP-10019
DOB:04/11/1988
Group:SAMPLE-OAK-ENDO-26
Authorization #:SAMPLE-SDP-VR-88419
Office
Office:Oakmont Endodontics & Specialists
Payer
Payer:Summit Dental Plan
Payer ID:SDP01
Type:PPO
Contact:800-555-0199
Portal:https://example.invalid/summit-dental
Network
Status:In Network
Network ID:SAMPLE-SDP-PPO
Plan
Plan:Summit Dental PPO
Effective:07/01/2023
Ends:12/31/2026
Policy effective:07/01/2023
Eligibility begins:07/01/2023
Benefit year:01/01/2026 – 12/31/2026
Plan product:Summit Dental PPO
Inquiry date:08/20/2026
Plan Limitations
Missing tooth clause:Yes — Prior extractions not replaced if extracted before the plan effective date. Tooth 30 extracted 11/02/2022, before coverage began 07/01/2023. Tooth 19 is present and is not subject to this clause.
D3330 Root Canal (Molar):Covered — Tooth 19 is present. Missing tooth clause does not apply to today's molar root canal.
D2740 Crown (Porcelain/Ceramic):Not covered — Replacement of tooth 30 is not covered — extracted 11/02/2022, before the plan effective date.
Dependent max age:26
Student max age:26
Specialty Maximums
Orthodontics
$1,500.00
Lifetime maximum
Predetermination & Special Rules
Predetermination:Requested above $300.00
Replacement clause:1 per 5 years
Medically necessary:Documentation required
Crown benefit paid:at seat (delivery)
Secondary Insurance 271
Payer:Ridgeview Mutual Dental (SAMPLE)
Relationship:secondary
Effective:01/01/2026
Plan Age Limits
Dependents
Through age 26
Dependent Age Cutoff
Students
Through age 26
Student Age Cutoff
Orthodontics
Covered:Yes
Lifetime max:$1,500.00
Used:$0.00
Remaining:$1,500.00
Flags for this patient
!This plan has a missing tooth clause: teeth lost before coverage began may not be covered for replacement (bridges, implants, dentures). Confirm the tooth's extraction date before treatment planning.
!Sealant (Per Tooth) (D1351) may not be covered again until 2102-06-15 — the plan's frequency limit has not reset since it was last done.
!Root Canal (Molar) (D3330) may not be covered again until 2119-06-04 — the plan's frequency limit has not reset since it was last done.
!Extraction (Erupted Tooth or Exposed Root) (D7140) may not be covered again until 2122-11-02 — the plan's frequency limit has not reset since it was last done.
!Occlusal Guard (Soft Appliance, Full Arch) (D9944) may not be covered again yet — the plan's frequency limit has not reset since it was last done.
▲This plan requires prior authorization for some services — send an authorization request before treatment.
▲This plan may pay some procedures at a lower-priced alternative — the patient may owe the difference between the planned service and what the plan allows.
iOther insurance coverage is on file for this patient — coordination of benefits may change what this plan pays.
iPre-authorization required
Revenue Opportunities
Review each item with the right team member before presenting it or contacting a family member. Internal — not a patient handout.
D0364 · CBCT — Limited Field of View
Review this covered option with the clinical team before presenting it to the patient.
80% plan coverage
Source: Reported plan coverage and the practice opportunity rules · Reported plan coverage · Ref D0364
D0220 · Periapical — First Film
Review this covered option with the clinical team before presenting it to the patient.
100% plan coverage
Source: Reported plan coverage and the practice opportunity rules · Reported plan coverage · Ref D0220
D0140 · Limited Oral Evaluation
Review this covered option with the clinical team before presenting it to the patient.
100% plan coverage
Source: Reported plan coverage and the practice opportunity rules · Reported plan coverage · Ref D0140
Coordination of benefits
Primary planACTIVE
Payer:Summit Dental Plan
Payer ID:SDP01
Member ID:SAMPLE-SDP-10019
Group:SAMPLE-OAK-ENDO-26
Benefit year:01/01/2026 – 12/31/2026
Evidence:Current 271
Secondary planACTIVE
Payer:Ridgeview Mutual Dental
Payer ID:RMD01
Member ID:SAMPLE-RMD-10019
Group:SAMPLE-RMD-26
Benefit year:01/01/2026 – 12/31/2026
Evidence:Current 271
Final patient responsibility requires claim adjudication.
Patient responsibilityPending plan adjudication
Pre-service estimate
Est. patient after COB $180.00 · non-duplication
Estimated cost by procedure after both plans
These are pre-service estimates from the patient’s current office fee schedule and both independently verified plans. A range means the payer’s coordination method is not documented. The final amount is set after both claims are processed.
| Code | Office fee | Primary pays | Secondary pays | Est. patient |
|---|---|---|---|---|
| D3330Root Canal (Molar) | $1,450.00 | $1,140.00 | $130.00 | $180.00 |
Coverage rules
Frequency, fees & limits
Procedure Codes · 22 tracked
How often the plan will pay for each procedure. Where the payer did not quote a code directly, the percentage is estimated from its service category and marked typical.
| Code | % | Ded | Office fee / plan allowed | Frequency | Last done | Details |
|---|---|---|---|---|---|---|
| Diagnostic | ||||||
| D0120Periodic Oral Exam | 100% | No | Office fee $65.00Allowable $48.00 | 2 per calendar year 1 of 2 used | 02/12/2026 | 2 per calendar year combined |
| D0140Limited Problem-Focused Exam | 100% | No | Office fee $95.00Allowable $72.00 | 2 per calendar year 0 of 2 used | 09/18/2025 | — |
| D0150Comprehensive Oral Exam | 100% | No | Office fee $98.00Allowable $72.00 | 2 per calendar year 0 of 2 used | 08/04/2023 | 2 per calendar year combined |
| D0180Comprehensive Periodontal Exam | 100% | No | Office fee $125.00Allowable $90.00 | 1 per calendar year 0 of 1 used | 06/11/2024 | — |
| D0210Full Mouth X-Rays | 100% | No | Office fee $185.00Allowable $140.00 | 1 per 5 years 0 of 1 used | 08/18/2021 | 1 per 5 years combined |
| D0220Periapical X-Ray (First) | 100% | No | Office fee $42.00Allowable $32.00 | 1 per 12 months 0 of 1 used | 11/02/2022 | — |
| D0272Bitewings (Two) | 100% | No | Office fee $62.00Allowable $45.00 | 1 per calendar year 0 of 1 used | 08/19/2024 | 1 per calendar year combined |
| D0274Bitewings (Four) | 100% | No | Office fee $85.00Allowable $62.00 | 1 per calendar year 0 of 1 used | 08/18/2025 | 1 per calendar year combined |
| D0330Panoramic X-Ray | 100% | No | Office fee $145.00Allowable $110.00 | 1 per 5 years 0 of 1 used | 09/12/2018 | 1 per 5 years combined |
| D0364Cone Beam CT (Limited) | 80% | Yes | Office fee $295.00Allowable $220.00 | 1 per 5 years 0 of 1 used | 06/04/2019 | — |
| Preventive | ||||||
| D1110Adult Cleaning (Prophylaxis) | 100% | No | Office fee $125.00Allowable $90.00 | 2 per calendar year 1 of 2 used Age 14+ only | 02/12/2026 | — |
| D1120Child Cleaning | 100% | No | Office fee $85.00Allowable $62.00 | 2 per calendar year 0 of 2 used Age ≤ 13 only | 04/11/2006 | — |
| D1206Fluoride Varnish | 100% | No | Office fee $45.00Allowable $32.00 | 2 per calendar year 0 of 2 used Age ≤ 18 only | 04/11/2006 | — |
| D1351Sealant (Per Tooth) | 100% | No | Office fee $55.00Allowable $40.00 | 1 per tooth per lifetime 0 of 1 used Age ≤ 15 only | 06/15/2002 next eligible 06/15/2102 | Benefit exhausted |
| Restorative | ||||||
| D2391Resin Filling (One Surface, Posterior) | 80% | Yes | Office fee $215.00Allowable $160.00 | 1 per 24 months 1 of 1 used | 03/22/2024 | Alternate benefit |
| D2740Crown (Porcelain/Ceramic) | 50% | Yes | Office fee $1,350.00Allowable $980.00 | 1 per 5 years 0 of 1 used | 03/15/2021 | Alternate benefit |
| D2950Core Buildup (Including Any Pins) | 50% | Yes | Office fee $285.00Allowable $210.00 | 1 per 5 years 0 of 1 used | 03/15/2021 | — |
| Endodontics | ||||||
| D3330Root Canal (Molar) | 80% | Yes | Office fee $1,450.00Allowable $980.00 | 1 per tooth 0 of 1 used | 06/04/2019 next eligible 06/04/2119 | Benefit exhausted |
| Periodontics | ||||||
| D4341Scaling & Root Planing (Per Quadrant, 4+ Teeth) | 80% | Yes | Office fee $285.00Allowable $210.00 | 1 per quadrant per 24 months 1 of 1 used Age 18+ only | 06/11/2024 | — |
| D4910Periodontal Maintenance | 80% | Yes | Office fee $125.00Allowable $90.00 | 2 per calendar year 0 of 2 used | 12/10/2025 | — |
| Oral Surgery | ||||||
| D7140Extraction (Erupted Tooth or Exposed Root) | 80% | Yes | Office fee $395.00Allowable $280.00 | 1 per tooth 1 of 1 used | 11/02/2022 next eligible 11/02/2122 | Benefit exhausted |
| Adjunctive | ||||||
| D9944Occlusal Guard (Soft Appliance, Full Arch) | Not covered | |||||
How often services are covered · 23 plan rules
See all frequency rulesThe most relevant rules also appear beside each procedure
| Code | Service | How often it is covered |
|---|---|---|
| D0120 | Periodic oral evaluation | 2 per calendar year |
| D0140 | Limited oral evaluation | 2 per calendar year |
| D0150 | Comprehensive oral evaluation | 2 per calendar year |
| D0180 | Comprehensive periodontal evaluation | 1 per calendar year |
| D0210 | Intraoral — complete series | 1 per 5 years |
| D0220 | Periapical — first film | 1 per 12 months |
| D0272 | Bitewings — two films | 1 per calendar year |
| D0274 | Bitewings — four films | 1 per calendar year |
| D0330 | Panoramic radiographic image | 1 per 5 years |
| D0364 | CBCT — limited field of view | 1 per 5 years |
| D1110 | Prophylaxis — adult | 2 per calendar year |
| D1120 | Prophylaxis — child | 2 per calendar year |
| D1206 | Topical fluoride varnish | 2 per calendar year |
| D1351 | Sealant — per tooth | 1 per tooth per lifetime |
| D2391 | Resin composite — one surface, posterior | 1 per 24 months |
| D2740 | Crown — porcelain/ceramic | 1 per 5 years |
| D2950 | Core buildup, including any pins | 1 per 5 years |
| D3330 | Molar root canal | 1 per tooth |
| D4341 | Periodontal scaling and root planing — four or more teeth per quadrant | 1 per quadrant per 24 months |
| D4910 | Periodontal maintenance | 2 per calendar year |
| D7140 | Extraction, erupted tooth or exposed root | 1 per tooth |
| D6010 | Surgical placement of implant body | 1 per site per lifetime |
| D6058 | Abutment supported porcelain/ceramic crown | 1 per 5 years |
Shared-Frequency Pools
Billing any code in a pool below uses up the allowance for every other code in the same pool.
Pool2 codes share one allowance
Every 60 months1 per 5 years combined
D0210D0330
Pool2 codes share one allowance
Every 12 months2 per calendar year combined
D0120D0150
Pool2 codes share one allowance
Every 12 months1 per calendar year combined
D0272D0274
Quadrant-Scoped Frequency Limits
SRP D4341 (per quadrant):Every 2 years
Replacement Limitations by Category
| Category | Replacement period |
|---|---|
| crowns | 60 months |
Plan reference
Appendix
Patient Coinsurance by Category
Patient share and plan coverage the portal stated for each named class.
Diagnostic:Patient in-network 0% · Patient out-of-network 40%
Endodontics:Patient in-network 20% · Patient out-of-network 50%
Restorations:Patient in-network 20% · Patient out-of-network 50%
Portal category coverage
Every named class the eligibility harvest returned, with the plan’s stated percentage.
Endodontics (ENDO):In-network 80% · Out-of-network 50%
Oral Exams (EXAM):In-network 100% · Last 02/12/2026
Radiographs (XRAY):In-network 100% · Last 08/18/2025
Crowns (CRN):In-network 50% · Last 03/15/2021
Family on this policy
Self:Summit Dental PPO · Group SAMPLE-OAK-ENDO-26 · Active
Specialty Accumulators
Orthodontics:Lifetime max $1,500.00 · remaining $1,500.00 · used $0.00 · 50% covered
Non-Covered Services & Exclusions
Not covered:
1 payer-reported procedure code, grouped by service type. Expand a group for details.
Adjunctive1 code
- D9944Occlusal Guard (Soft Appliance, Full Arch)
Excluded by plan:
1 payer-reported procedure code, grouped by service type. Expand a group for details.
Adjunctive1 code
- D9995Teledentistry (Synchronous, Real-Time)
D9944:Occlusal guards are not covered under this plan.
More procedures listed by the plan · 2
See all additional proceduresUse this when you need a procedure not shown above
| Code | Category | Coverage | Frequency | Last done | Network | Notes |
|---|---|---|---|---|---|---|
| D6010Implant Body (Endosteal) | implant_services | 50% | 1 per site per lifetime | — | PPO | Plan allowed $1,200.00Never performed per payer records |
| D6058Implant Abutment | implant_services | 50% | 1 per 5 years | — | PPO | Plan allowed $980.00Never performed per payer records |
Additional Covered Procedure Codes · 4 named by payer
These services were named by the payer. This is plan detail, not a treatment recommendation or confirmation of eligibility today.
4 payer-reported procedure codes, grouped by service type. Expand a group for details.
Diagnostic3 codes
- D0140Limited Problem-Focused Exam
- D0220Periapical X-Ray (First)
- D0364Cone Beam CT (Limited)
Endodontics1 code
- D3330Root Canal (Molar)
Coverage by Network Tier
PPO:Annual max $1,500.00 · Remaining $1,140.00 · Deductible $50.00 · Deductible remaining $0.00
Out of network:Annual max $1,000.00 · Remaining $1,000.00 · Deductible $100.00 · Deductible remaining $100.00
Downgrades & Alternate Benefits
Anterior composites: not downgraded — payer confirmed
D2391, D2392:composite → amalgam
Alternate benefit:posterior composite to amalgam — “Posterior composites paid as amalgam”
Payer Conditions
- Pre-authorization required
Additional Procedure Restrictions
- Endodontic benefits apply to in-network specialty providers.
Pending / Estimated Adjustments
Ytd Hold:$360.00 (individual)
How Sally read this response
See Sally's reasoningUse this when a coverage detail needs review
This explains how Sally organized the payer response. It is not a statement from the payer.
- Plan classified active because the portal harvest returned an active status and a current benefit year.
Payer Could Not Quote
The payer quoted every requested category — no coverage gaps reported.Plan details
See plan descriptionsAdditional wording returned by the payer
- Employer group dental plan for Oakmont Endodontics & Specialists staff families. (service type 35)
Notes from the payer
See payer notesDetails remain available without crowding today's decisions
- Benefits subject to annual re-verification.
- Contact Summit provider services for prior authorization on molar root canals.
Treatment History
Permanent teeth with work on file · 4 teeth. Last DOS is the portal service date — the payer tooth view reprints that same date as End Date.
| Tooth | Codes | Last DOS | Surfaces |
|---|---|---|---|
| 3 | D3330, D4341, D0364, D1351 | 06/11/2024 | UR |
| 14 | D2740, D2950 | 03/15/2021 | — |
| 30 | D7140, D0220 | 11/02/2022 | — |
| 18 | D2391 | 03/22/2024 | — |
Every portal history row, including exams and cleanings with no tooth number.
| Code | Service date | Tooth | Surfaces | Network | Remaining | Next eligible |
|---|---|---|---|---|---|---|
| D3330Molar RCT | 06/04/2019 | 3 | — | In-network | Eligible on other teeth | 06/04/2119 |
| D2740Crown — porcelain/ceramic | 03/15/2021 | 14 | — | In-network | — | 03/15/2026 |
| D2950Core buildup | 03/15/2021 | 14 | — | In-network | — | — |
| D7140Extraction | 11/02/2022 | 30 | — | In-network | — | 11/02/2122 |
| D0220Periapical — first film | 11/02/2022 | 30 | — | In-network | — | — |
| D0150Comprehensive oral evaluation | 08/04/2023 | — | — | In-network | — | — |
| D2391Resin composite — one surface, posterior | 03/22/2024 | 18 | — | In-network | — | — |
| D0180Comprehensive periodontal evaluation | 06/11/2024 | — | — | In-network | — | — |
| D4341SRP — four or more teeth per quadrant | 06/11/2024 | 3 | UR | In-network | — | — |
| D0272Bitewings — two films | 08/19/2024 | — | — | In-network | — | — |
| D4910Periodontal maintenance | 12/10/2025 | — | — | In-network | — | — |
| D0120Periodic oral evaluation | 02/12/2026 | — | — | In-network | 1 of 2 used | — |
| D1110Adult prophylaxis | 02/12/2026 | — | — | In-network | — | — |
| D0274Bitewings — four films | 08/18/2025 | — | — | In-network | — | 01/01/2026 |
| D0210Intraoral — complete series | 08/18/2021 | — | — | In-network | — | 08/18/2026 |
| D0330Panoramic radiographic image | 09/12/2018 | — | — | In-network | — | — |
| D0364CBCT — limited field of view | 06/04/2019 | 3 | — | In-network | — | 06/04/2024 |
| D0140Limited oral evaluation | 09/18/2025 | — | — | In-network | — | — |
| D1120Prophylaxis — child | 04/11/2006 | — | — | In-network | — | — |
| D1206Topical fluoride varnish | 04/11/2006 | — | — | In-network | — | — |
| D1351Sealant — per tooth | 06/15/2002 | 3 | — | In-network | — | 06/15/2102 |
Verification Log
portal Eligibility verified via payer portal · 08/20/2026
Coverage summary
Summit Dental Plan verified L. Anderson through the payer portal at 4:51 AM on Aug 20, 2026. Today's visit is a molar root canal (D3330) on tooth 19. Annual remaining of $1,140.00 caps the plan payment. Add-on offers are limited-field CBCT, a periapical film, and a limited oral evaluation.
Scheduled Treatment Estimate
Pre-service estimate only — payer adjudication and clinical decisions can change the final amount.
Estimate status:Pre service estimate
Service date:08/20/2026
Submitted fees:$1,882.00
Estimated insurance:$1,140.00
Estimated patient:$742.00
Patient upper bound:$742.00
| Scheduled code | Fee | Coverage | Est. insurance | Est. patient | Frequency |
|---|---|---|---|---|---|
| D3330Tooth 19 | $1,450.00 | 80% | $1,140.00 | $310.00 | Eligible |
| D0364Tooth 19 | $295.00 | 80% | $0.00 | $295.00 | Eligible |
| D0220Tooth 19 | $42.00 | 100% | $0.00 | $42.00 | Eligible |
| D0140Limited Problem-Focused Exam | $95.00 | 100% | $0.00 | $95.00 | Eligible |
More details from the payer
See all remaining payer detailsNothing is removed; technical details stay out of the main view
- Other payer details
- Used quantity: 0
- 1 per site per lifetime
- Period kind: lifetime
- Used quantity: 0
- Timing and frequency limits
- Frequency display: 1 per 5 years
- Period kind: years
- Requirements before treatment
- Similar procedures performed on the same date of service are subject to review
Prepared by Sally · Verified via payer portalForm: Front Desk StandardCombined primary and secondary estimate; final responsibility is confirmed after both claims are processed
Estimate only · not a bill · coverage subject to claim adjudicationVerora Precision · Summit Dental Plan