| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
27 |
27 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
23 |
23 |
$885.04 |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$530.32 |
| D0120 |
Periodic oral evaluation - established patient |
24 |
24 |
$524.60 |
| D1120 |
Prophylaxis - child |
18 |
18 |
$512.67 |
| D1208 |
Topical application of fluoride, excluding varnish |
32 |
32 |
$508.48 |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
29 |
$372.07 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$282.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
19 |
$197.41 |