| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
165 |
101 |
$9K |
| D1110 |
Prophylaxis - adult |
145 |
141 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
177 |
168 |
$3K |
| D1120 |
Prophylaxis - child |
153 |
149 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
343 |
328 |
$2K |
| D1206 |
Topical application of fluoride varnish |
202 |
197 |
$2K |
| D0274 |
Bitewings - four radiographic images |
150 |
143 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
117 |
116 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
343 |
281 |
$2K |
| D0272 |
Bitewings - two radiographic images |
66 |
66 |
$829.40 |
| D0140 |
Limited oral evaluation - problem focused |
56 |
54 |
$802.70 |
| D0330 |
Panoramic radiographic image |
16 |
15 |
$466.60 |