| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
473 |
473 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
567 |
565 |
$14K |
| D0274 |
Bitewings - four radiographic images |
247 |
247 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
210 |
210 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
113 |
111 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
67 |
$5K |
| D4341 |
|
31 |
13 |
$4K |
| D0330 |
Panoramic radiographic image |
45 |
45 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
159 |
150 |
$3K |