| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
666 |
666 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,030 |
987 |
$9K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
15 |
13 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
370 |
370 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
743 |
723 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
25 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
142 |
142 |
$3K |
| D1320 |
|
270 |
270 |
$2K |
| D2394 |
|
20 |
15 |
$2K |
| D0274 |
Bitewings - four radiographic images |
53 |
53 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
13 |
$929.08 |
| D0210 |
Intraoral - complete series of radiographic images |
105 |
82 |
$852.34 |
| D1120 |
Prophylaxis - child |
15 |
15 |
$438.12 |
| D1208 |
Topical application of fluoride, excluding varnish |
30 |
30 |
$320.03 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$159.65 |