| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
359 |
359 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
309 |
309 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
499 |
489 |
$6K |
| D0274 |
Bitewings - four radiographic images |
134 |
134 |
$4K |
| D1120 |
Prophylaxis - child |
47 |
47 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
287 |
275 |
$2K |
| D0272 |
Bitewings - two radiographic images |
77 |
77 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
43 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$782.60 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$495.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$242.20 |