| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
161 |
161 |
$8K |
| D1206 |
Topical application of fluoride varnish |
172 |
172 |
$7K |
| D1120 |
Prophylaxis - child |
109 |
109 |
$6K |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$4K |
| D0272 |
Bitewings - two radiographic images |
82 |
82 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
13 |
$3K |
| D1110 |
Prophylaxis - adult |
38 |
38 |
$3K |
| D0274 |
Bitewings - four radiographic images |
43 |
43 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$354.00 |