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DENTAL RECEIPT
Provider:
BrightSmile Dental Clinic
Phone: (312) 555-0122
Patient: Noah Carter
02/14/2026, 17:29:29
D0150 Comprehensive Oral Exam
$45.00
D1110 Prophylaxis (Adult Cleaning)
$70.00
D1206 Fluoride Varnish
$25.00
Tooth Ref: #14 (Noted)
$0.00
TOTALS
$140.00
Method
Card
Refge
33490188012A
Status
APPROVED
Receipt ID: DEN-20260214-0140
For dental insurance / FSA reimbursement.
Dental Receipt
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