| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
238 |
238 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
261 |
261 |
$6K |
| D0274 |
Bitewings - four radiographic images |
227 |
227 |
$3K |
| D1120 |
Prophylaxis - child |
38 |
38 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
322 |
320 |
$2K |
| D1206 |
Topical application of fluoride varnish |
49 |
49 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
252 |
251 |
$906.22 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$520.00 |