| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
208 |
207 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
323 |
322 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
107 |
104 |
$6K |
| D0274 |
Bitewings - four radiographic images |
136 |
136 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
304 |
294 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
149 |
149 |
$4K |
| D0330 |
Panoramic radiographic image |
45 |
42 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
244 |
227 |
$3K |
| D1120 |
Prophylaxis - child |
16 |
16 |
$628.96 |