| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
116 |
116 |
$3K |
| D1110 |
Prophylaxis - adult |
58 |
58 |
$3K |
| D0274 |
Bitewings - four radiographic images |
66 |
66 |
$2K |
| D1120 |
Prophylaxis - child |
47 |
47 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
116 |
116 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
111 |
111 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
111 |
109 |
$1K |
| D0272 |
Bitewings - two radiographic images |
37 |
37 |
$841.68 |
| D0603 |
|
100 |
99 |
$0.00 |
| D0601 |
|
12 |
12 |
$0.00 |