Dental Claims
ADA dental claim form — CDT procedure coding with tooth chart and surface documentation
Patient Information
Member demographics
Subscriber / Insurance
Primary coverage details
Tooth Chart
Click teeth to select for procedure entry
Treated
Pending
Selected
Healthy
Upper Arch (Maxillary)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
MIDLINE
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
Lower Arch (Mandibular)
Procedures
CDT coded dental procedures
| Tooth # | Surfaces | ADA Code | Description | Fee | Status | |
|---|---|---|---|---|---|---|
|
|
Approved | |||||
|
|
Approved | |||||
|
|
Pending Auth | |||||
|
|
In Review | |||||
|
|
Approved |
Subtotal: $2,667.00
Estimated Benefit: $1,866.90
Patient Responsibility: $800.10