Queue›Emily Rodriguez›Estimate

Treatment estimate

Emily Rodriguez · Delta Dental Delta Dental PPO · Apr 24, 2026
Patient owes
$0.00
due at or before treatment
Insurance pays
$412.00
of $412.00 total fee
After this plan
$785.96
remaining balance
CodeTreatmentQtyFeeCoveredDed.InsurancePatient
D0140
Limited oral evaluation
1$85.00100%—$85.00$0.00
D0120
Periodic oral evaluation
1$52.00100%—$52.00$0.00
D0274
Bitewings — four films
1$75.00100%—$75.00$0.00
D0330
Panoramic radiograph
1$120.00100%—$120.00$0.00
D1120
Prophylaxis — child
1$80.00100%—$80.00$0.00