| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
211 |
211 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
147 |
147 |
$6K |
| D1206 |
Topical application of fluoride varnish |
156 |
156 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
274 |
127 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
161 |
159 |
$2K |
| D0274 |
Bitewings - four radiographic images |
56 |
56 |
$2K |
| D0330 |
Panoramic radiographic image |
31 |
31 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
55 |
55 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
19 |
19 |
$457.52 |