| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
493 |
406 |
$19K |
| D1351 |
Sealant - per tooth |
220 |
100 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
495 |
408 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
483 |
396 |
$12K |
| D0274 |
Bitewings - four radiographic images |
114 |
114 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
89 |
88 |
$2K |
| D1110 |
Prophylaxis - adult |
39 |
39 |
$2K |
| D0272 |
Bitewings - two radiographic images |
103 |
100 |
$968.20 |
| D0220 |
Intraoral - periapical first radiographic image |
100 |
99 |
$554.40 |
| D0140 |
Limited oral evaluation - problem focused |
30 |
30 |
$486.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
26 |
$163.40 |
| D0601 |
|
67 |
65 |
$13.50 |
| D0602 |
|
61 |
59 |
$12.75 |
| D0603 |
|
17 |
17 |
$5.25 |