Queue›Emily Rodriguez›Estimate

Treatment estimate

Emily Rodriguez · Delta Dental Delta Dental PPO · Apr 23, 2026
Patient owes
$0.00
due at or before treatment
Insurance pays
$302.00
of $302.00 total fee
After this plan
$5.25
remaining balance
CodeTreatmentQtyFeeCoveredDed.InsurancePatient
D0120
Periodic oral evaluation
1$52.00100%—$52.00$0.00
D0274
Bitewings — four films
1$75.00100%—$75.00$0.00
D1120
Prophylaxis — child
1$80.00100%—$80.00$0.00
D1351
Sealant per tooth
1$60.00100%—$60.00$0.00
D0220
Periapical first radiograph
1$35.00100%—$35.00$0.00