| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
152 |
90 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
87 |
58 |
$12K |
| D1206 |
Topical application of fluoride varnish |
237 |
234 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
331 |
329 |
$8K |
| D1120 |
Prophylaxis - child |
144 |
141 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
276 |
256 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
152 |
150 |
$7K |
| D0274 |
Bitewings - four radiographic images |
57 |
57 |
$3K |
| D0272 |
Bitewings - two radiographic images |
75 |
72 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
21 |
18 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
12 |
$713.00 |