Queue›Maria Chen›Estimate

Treatment estimate

Maria Chen · Delta Dental Delta Dental PPO · Apr 22, 2026
Patient owes
$472.93
due at or before treatment
Insurance pays
$44.07
of $517.00 total fee
After this plan
$0.00
annual max will be exhausted
⚠ Max impactInsurance would normally pay an additional $472.93 on this treatment, but the annual max cap shifts that amount to the patient. Consider deferring D0120 to 2027.
CodeTreatmentQtyFeeCoveredDed.InsurancePatient
D0120
Periodic oral evaluation
1$52.00100%—$44.07$7.93
D0140
Limited oral evaluation
1$85.00100%—$0.00$85.00
D0210
Full-mouth intraoral radiographs
1$150.00100%—$0.00$150.00
D0220
Periapical first radiograph
1$35.00100%—$0.00$35.00
D0274
Bitewings — four films
1$75.00100%—$0.00$75.00
D0330
Panoramic radiograph
1$120.00100%—$0.00$120.00