| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
58 |
58 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
132 |
132 |
$2K |
| D1120 |
Prophylaxis - child |
61 |
61 |
$2K |
| D0274 |
Bitewings - four radiographic images |
46 |
46 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
51 |
51 |
$637.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
21 |
21 |
$588.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$528.00 |
| D1206 |
Topical application of fluoride varnish |
30 |
30 |
$471.25 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
15 |
$384.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$156.00 |