| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
898 |
898 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,076 |
1,076 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
354 |
353 |
$3K |
| D0274 |
Bitewings - four radiographic images |
78 |
78 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
132 |
131 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
97 |
97 |
$822.40 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
14 |
$750.25 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$347.64 |
| D1999 |
|
42 |
39 |
$0.00 |