| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
86 |
86 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
264 |
83 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
228 |
225 |
$2K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$1K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$1K |
| D1206 |
Topical application of fluoride varnish |
59 |
59 |
$852.60 |
| D1208 |
Topical application of fluoride, excluding varnish |
55 |
55 |
$777.63 |
| D0120 |
Periodic oral evaluation - established patient |
27 |
27 |
$770.34 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$257.18 |
| D0603 |
|
355 |
351 |
$9.07 |