| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
727 |
726 |
$13K |
| D1110 |
Prophylaxis - adult |
365 |
362 |
$13K |
| D1206 |
Topical application of fluoride varnish |
314 |
314 |
$5K |
| D1120 |
Prophylaxis - child |
157 |
157 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
33 |
33 |
$651.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
21 |
21 |
$522.73 |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$294.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$62.25 |