| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D9110 |
|
129 |
122 |
$8K |
| D1110 |
Prophylaxis - adult |
67 |
67 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
72 |
72 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
12 |
$3K |
| D1206 |
Topical application of fluoride varnish |
133 |
133 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
382 |
235 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
118 |
102 |
$1K |
| D0330 |
Panoramic radiographic image |
30 |
30 |
$870.00 |
| D0350 |
|
72 |
25 |
$643.20 |
| D0274 |
Bitewings - four radiographic images |
64 |
64 |
$626.40 |