| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
165 |
162 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
256 |
254 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
65 |
46 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
83 |
54 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
147 |
144 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
100 |
100 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
63 |
63 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
102 |
95 |
$3K |
| D0274 |
Bitewings - four radiographic images |
77 |
75 |
$2K |
| D1120 |
Prophylaxis - child |
44 |
44 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
92 |
90 |
$1K |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$320.00 |
| D0270 |
|
12 |
12 |
$132.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$126.00 |