| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
545 |
545 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
537 |
535 |
$15K |
| D1206 |
Topical application of fluoride varnish |
508 |
508 |
$14K |
| D2740 |
Crown - porcelain/ceramic |
37 |
29 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
380 |
380 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
154 |
122 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
190 |
189 |
$6K |
| D0330 |
Panoramic radiographic image |
197 |
197 |
$5K |
| D0274 |
Bitewings - four radiographic images |
215 |
214 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
167 |
165 |
$3K |
| D1110 |
Prophylaxis - adult |
52 |
51 |
$2K |
| D2950 |
|
20 |
15 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
167 |
163 |
$1K |
| D0272 |
Bitewings - two radiographic images |
44 |
44 |
$476.87 |