This is a fabricated example. No real patient, plan, or carrier data. "Keystone Dental PPO" and "Northfield Logistics" are invented. Values are typical-looking, not quoted from any real plan. Use it to show offices the format they will receive.
Verified Chair — Benefits Breakdown
Office: Sample Family Dentistry (Office ID SFD-001) · Appointment: Tue 11/17/2026 9:00 AM · Provider: Dr. A (General)
Verified: 11/12/2026 2:41 PM CT · Method: Carrier portal + phone confirmation · Carrier call ref #: KDP-7781-2290 (rep "Maria") · Verifier: V-03 · QA: Sampled ✔ (QA-01)
1. Prophy frequency: last D1110 on 06/02/2026 → plan allows 2 per calendar year; 1 remaining in 2026 → OK for 11/17.
2. Bitewings (D0274) NOT due: last taken 03/10/2026; limit 1 per 12 months → eligible again 03/10/2027. Recommend no BWX this visit or patient pays.
3. Crown #30 (D2740) on treatment plan: pre-treatment estimate recommended (carrier advises, not required); 5-year replacement rule — tooth #30 has no crown history on file with carrier.
4. Remaining annual max is low: $412 of $1,500 remains for 2026. Plan year resets 01/01/2027 → consider scheduling crown in January if clinically appropriate (clinical decision belongs to the dentist).
| Field | Value |
|---|---|
| Patient | J. D. (DOB //1984) — Relationship: Self |
| Subscriber | Same |
| Employer / Group | Northfield Logistics · Group # 00-48213 |
| Member ID | ••••••4471 (full ID in PMS only) |
| Carrier / Plan | Keystone Dental PPO — "PPO Plus 1500" |
| Payer ID / Claims address | 99999 · PO Box 0000, Springfield, ST 00000 |
| Coverage status | Active · Effective 01/01/2024 · No termination date on file |
| Network status | In-network (office TIN on carrier's PPO roster) |
| Fee schedule | Carrier PPO fee schedule applies (office's contracted fees) |
| Plan year | Calendar year (Jan–Dec) |
| Coordination of benefits | No other coverage on file · Standard COB |
| Individual | Family | |
|---|---|---|
| Annual maximum | $1,500 — remaining $412 | n/a |
| Deductible | $50 — met | $150 — met $100 |
| Deductible applies to | Basic & Major (waived for Preventive/Diagnostic) | |
| Ortho lifetime max | Not covered (adult) / dependent child to age 19: $1,000 |
| Category | Coverage | Waiting period |
|---|---|---|
| Diagnostic & Preventive (exams, cleanings, X-rays, fluoride) | 100% | None |
| Basic (fillings, simple extractions) | 80% | None |
| Endodontics / Periodontics | 80% | None |
| Oral surgery | 80% | None |
| Major (crowns, bridges, dentures, implants) | 50% | 12 months — satisfied 01/01/2025 |
| Code | Description | Limitation | Last date of service (per carrier) | Eligible 11/17? |
|---|---|---|---|---|
| D0120 | Periodic oral eval | 2 / calendar year | 06/02/2026 | ✅ Yes |
| D0150 | Comprehensive eval | 1 / 36 months per provider | 01/15/2024 | ✅ Yes (counts toward eval limit) |
| D1110 | Adult prophylaxis | 2 / calendar year (shares with D4910) | 06/02/2026 | ✅ Yes (last one for 2026) |
| D4910 | Perio maintenance | Shares with D1110 · 2 / yr at 80% | none | — |
| D0274 | 4 bitewings | 1 / 12 months | 03/10/2026 | ❌ No — 03/10/2027 |
| D0210 / D0330 | FMX / Pano | 1 / 60 months (either) | 01/15/2024 (D0210) | ❌ No — 01/15/2029 |
| D1206 | Fluoride varnish | To age 14 only | — | ❌ Not covered (age) |
| D1351 | Sealant | Permanent molars to age 16 | — | ❌ Not covered (age) |
| D4341/D4342 | SRP | 1 per quadrant / 24 months · 80% | none | ✅ Yes |
| D2740 | Crown — porcelain/ceramic | 1 per tooth / 5 years · 50% | none on #30 | ✅ Yes (estimate recommended) |
| D2391–D2394 | Posterior composite | Downgraded to amalgam allowance | — | ⚠️ Patient pays difference |
| D6010 | Implant | 50% · 1 per tooth / 5 yrs | — | ✅ Covered |
| D9230 | Nitrous | Not covered | — | ❌ |
- Missing-tooth clause: Yes — teeth missing before coverage effective date are excluded from replacement (bridges/implants/partials).
- Alternate benefit / downgrade: posterior composites paid at amalgam rate; porcelain on molars paid at full-metal rate — NOT on this plan for crowns (per rep).
- Preventive & diagnostic do NOT count toward the annual maximum on this plan (per rep) — today's visit leaves $412 remaining.
- Pre-authorization: not required; pre-treatment estimate recommended for any service > $300.
- Same-day crown/buildup (D2950) with crown: buildup paid only if needed for retention (narrative + X-ray required).
| Code | Office contracted fee* | Coverage | Est. insurance | Est. patient |
|---|---|---|---|---|
| D0120 | $48 | 100% | $48 | $0 |
| D1110 | $92 | 100% | $92 | $0 |
| D0274 (if taken anyway) | $66 | Not eligible | $0 | $66 |
| Visit total (without BWX) | $140 | $140 | $0 |
*Contracted fees are placeholders; on the live service we use the office's fee schedule from the PMS.
| Fee* | Coverage | Est. insurance | Est. patient |
|---|---|---|---|
| $1,040 | 50% (deductible met) | $520 → capped at remaining max $412 if done in 2026 | $628 in 2026 vs ≈ $520 in 2027 (if max resets and unused) |
Estimates are based on information the carrier reported on the date/time above and are not a guarantee of payment. Final payment is determined by the carrier when the claim is processed.
Delivered as PDF to the office's secure folder; Pro plan also keys benefits, frequencies, and coverage table into the PMS insurance plan record. No PHI is ever sent in email body text.