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Pediatric Sedation

Online Scheduling (Old)


Anesthesia Fee Estimate Form

Estimated Dental
Procedure Minutes
Total Prepaid Fee Deposit due at scheduling Balance due prior to procedure
5 $390 $250 $140
20 $550 $250 $300
40 $775 $250 $525
60 $975 $250 $725
80 $1200 $250 $950
100 $1400 $250 $1150
120 $1650 $250 $1400
140 $1900 $250 $1650
160 $2150 $250 $1900
180 $2400 $250 $2150
200 $2700 $250 $2450
220 $2900 $250 $2650
240 $3200 $250 $2950

Estimated anesthesia minutes given by dentist:

Payment Policy:

  •  $250 Deposit is due at the time of scheduling. There is a $250 charge for patients who fail to keep the IV
    Sedation appointment without giving a 24 hour notice.
  •  Our financial office can help patients with medical insurance determine their out of network benefits. On the
    date of service you will be given a Superbill to file the anesthesia through your out of network benefits. Many
    medical insurance companies do not cover anesthesia services for office based dental care, however, PDAA
    is commuted to fully assisting you with the pursuit of any potential reimbursement.
  • Your dental treatment plan may change after treatment is begun. Charges for anesthesia services may be
    more or less than the estimated amount based on the final length of the procedure. The anesthesia charges
    may be more than initially estimated and an additional payment by credit card is due at the time of
    service. Any overpayments will be refunded automatically to you.
  • We accept cashier’s check , American Express, Discover, Visa, MasterCard, and Carecredit for payment in
    full 3 business days before the patient is treated. You can apply for Carecredit at www.carecredit.com
  • I understand that my health plan (Tricare and other plans) may impose a limit on balance billing by out of
    network providers. I wish to waive any limit on balance billing and receive treatment from this out of network
    provider.
  • I understand that I am seeking the care of PDAA for a service that may not be covered by my insurance
    company. I understand that my insurance plan may not cover any part of the charges, costs or expenses
    related to Anesthesia services and I will be responsible for all charges incurred.

Parent/Guardian:

Date: December 5, 2022

Leave this empty:

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Signature Certificate
Document name: Online Scheduling (Old)
lock iconUnique Document ID: bdae46ca542ed2c07c51c4a09f4d7d9727c52cc6
Timestamp Audit
February 27, 2021 12:09 pm ESTOnline Scheduling (Old) Uploaded by Pediatric Dental Anesthesia Associates - alan.campbell@castawaylabs.com IP 47.201.198.107
March 3, 2021 8:35 am ESTPediatric Sedation - billing@pediatricsedation.com added by Alan Campbell - alan.campbell@castawaylabs.com as a CC'd Recipient Ip: 47.201.198.107
March 3, 2021 8:35 am ESTAlan Support - alan.campbell@castawaylabs.com added by Alan Campbell - alan.campbell@castawaylabs.com as a CC'd Recipient Ip: 47.201.198.107
March 4, 2021 9:09 pm ESTPediatric Sedation - billing@pediatricsedation.com added by Pediatric Dental Anesthesia Associates - alan.campbell@castawaylabs.com as a CC'd Recipient Ip: 47.201.198.107
March 4, 2021 9:09 pm ESTAlan Support - alan.campbell@castawaylabs.com added by Pediatric Dental Anesthesia Associates - alan.campbell@castawaylabs.com as a CC'd Recipient Ip: 47.201.198.107
March 5, 2021 8:12 am ESTPediatric Sedation - billing@pediatricsedation.com added by Pediatric Dental Anesthesia Associates - alan.campbell@castawaylabs.com as a CC'd Recipient Ip: 47.201.198.107
March 5, 2021 8:12 am ESTAlan Support - alan.campbell@castawaylabs.com added by Pediatric Dental Anesthesia Associates - alan.campbell@castawaylabs.com as a CC'd Recipient Ip: 47.201.198.107