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On June 3, we will be upgrading our benefits administration system. As part of this upgrade, the employer portal will be updated, and new user registrations will not be available until June 3. Please visit our upgrade resources and FAQs to learn more. |
| Current Location: | Home > Interactive Demonstration > Employer Connection > Benefits & Eligibility > Sample EOB |
May 19, 2026
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 | EXPLANATION OF BENEFITS |
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| HARVEY J SCHNEIDER 100 MAIN STREET STEVENS POINT WI 544810000 | Patient: | HARVEY J SCHNEIDER |
|---|---|---|
| Group No. | 93705-000-00000-00000 | |
| Claim No. | 0-6345-314-49 | |
| Check No. | 2603172 | |
| Payment Date: | 12/20/2006 | |
| DDS License No: | 333259162 USA 008 |
| TTH# | Date of Service | Proc. Code | Description | Submitted Amount | Approved Amount | Allowed Amount | % copay | * ** | COB | Patient Pay | Delta Pay | Ref code |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 18 | 12/06/06 | 02140 | FILLING | $107.00 | $85.00 | $85.00 | 80 | - | $.00 | $17.00 | $68.00 | - |
| $17.00 | $68.00 | |||||||||||
| THIS IS NOT A BILL | Total | Total | ||||||||||
| Check No: | 2603172 | Payment Date: | 12/20/2006 |
| Payee Name: | MIDWEST DENTAL CARE | ||
| Address: | PO BOX 90 ANYWHERE USA 555550000 | ||
Voucher Explanation
Submitted Amount: The amount billed/charged for the procedure.
Approved Amount: The amount approved for total patient/Delta payment.
Allowed Amount: The allowed fee for the covered procedure used to calculate Delta's payment.
* = Exceeds Maximum: Indicates the service exceeds patient/group benefit year maximum.
** = Deductible: Indicates patient/group must meet deductible for all or a portion of the service.