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.
May 18, 2021
Your cost: $0.00
Quin Parker
- Cleaning
- Fluoride treatment
Your cost: $0.00
Your dentistDenise Allen
(415)-921-5555
(415)-921-5555
Cost summary
Submitted fee$170.00
The submitted fee is the amount that the dental office charges for your service.Accepted fee$170.00
The accepted fee is the amount your dentist agrees to accept as full payment for your dental service.Delta Dental pays$170.00
“Delta Dental pays” is the dollar amount paid by your dental plan.Your cost
$0.00
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
(D1110) prophylaxis (cleaning) - adult
Your cost for this procedure
$0.00
Submitted fee $111.00
Accepted fee
Delta Dental pays
Your cost for this procedure$0.00
(D1206) topical application of fluoride varnish
Your cost for this procedure
$0.00
Submitted fee $59.00
Accepted fee
Delta Dental pays
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.