| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
42 |
42 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
55 |
55 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
39 |
39 |
$962.00 |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$902.00 |
| D0274 |
Bitewings - four radiographic images |
47 |
47 |
$676.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$547.30 |
| D0220 |
Intraoral - periapical first radiographic image |
82 |
82 |
$448.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
74 |
73 |
$342.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$210.60 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$94.00 |