| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
200 |
70 |
$8K |
| D1120 |
Prophylaxis - child |
191 |
191 |
$7K |
| D1354 |
|
195 |
77 |
$6K |
| D1206 |
Topical application of fluoride varnish |
160 |
160 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
77 |
77 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
111 |
111 |
$4K |
| D0272 |
Bitewings - two radiographic images |
118 |
118 |
$2K |
| D0274 |
Bitewings - four radiographic images |
20 |
20 |
$746.70 |
| D1208 |
Topical application of fluoride, excluding varnish |
46 |
45 |
$660.00 |
| D0220 |
Intraoral - periapical first radiographic image |
42 |
42 |
$403.03 |
| D0230 |
Intraoral - periapical each additional radiographic image |
40 |
38 |
$383.37 |