| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
24 |
24 |
$634.82 |
| D0274 |
Bitewings - four radiographic images |
18 |
18 |
$510.66 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$436.54 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$275.15 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$226.98 |
| D0220 |
Intraoral - periapical first radiographic image |
32 |
32 |
$218.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
18 |
$156.96 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$0.00 |