| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
928 |
915 |
$20K |
| D1120 |
Prophylaxis - child |
395 |
392 |
$12K |
| D1206 |
Topical application of fluoride varnish |
625 |
622 |
$10K |
| D1110 |
Prophylaxis - adult |
146 |
146 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
72 |
72 |
$1K |
| D0274 |
Bitewings - four radiographic images |
32 |
32 |
$971.84 |
| D1351 |
Sealant - per tooth |
37 |
13 |
$902.80 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$585.24 |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$530.70 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$476.00 |