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Benefits & coverage

Visit details

This Explanation of Benefits (EOB) is a summary of your dental visit. You can review the services performed and how your plan applied to the visit.

Oct 18, 2021

Quin Parker

  • Filling (tooth colored) - 3
Your cost: $322.00
Your dentistDenise Allen
(415)-921-5555

Cost summary

Submitted fee$1,467.00
The submitted fee is the amount that the dental office charges for your service.
Accepted fee$1,414.00
The accepted fee is the amount your dentist agrees to accept as full payment for your dental service.
Delta Dental pays$1,092.00
“Delta Dental pays” is the dollar amount paid by your dental plan.

Your cost

$322.00

This Explanation of Benefits is not a bill — think of it as a receipt for your visit. Typically, any balance that you owe is paid to your dentist. If you would like to discuss billing, please feel free to contact your dentist.

Cost details

Claim number20213403005120

Procedures and services on this visit

Submitted fee $238.00
Accepted fee $238.00
Delta Dental pays$238.00
Your cost for this procedure$0.00
Submitted fee $238.00
Accepted fee $238.00
Delta Dental pays$238.00
Your cost for this procedure$0.00
Submitted fee $644.00
Accepted fee $644.00
Delta Dental pays$322.00
Your cost for this procedure$322.00
Submitted fee $347.00
Accepted fee $294.00
Delta Dental pays$294.00
Your cost for this procedure$0.00

Your total cost

This is not a bill. Billing for dental services is typically handled by your dentist's office. If you have questions about your bill, please contact your dentist.

Your cost

$322.00