| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
862 |
862 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,063 |
1,063 |
$29K |
| D4910 |
|
413 |
413 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,131 |
1,131 |
$21K |
| D0274 |
Bitewings - four radiographic images |
510 |
510 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
899 |
881 |
$11K |
| D4342 |
|
101 |
39 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
174 |
173 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
166 |
161 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
607 |
576 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
26 |
$3K |
| D4341 |
|
30 |
13 |
$3K |
| D9630 |
|
93 |
93 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D1999 |
|
136 |
127 |
$952.00 |
| D1330 |
|
59 |
59 |
$570.00 |
| D0180 |
|
12 |
12 |
$504.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$204.00 |