| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
823 |
821 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
746 |
745 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
268 |
177 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
488 |
487 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
240 |
239 |
$10K |
| D1206 |
Topical application of fluoride varnish |
357 |
355 |
$8K |
| D0274 |
Bitewings - four radiographic images |
544 |
542 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
104 |
102 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
623 |
619 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
522 |
520 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
28 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
107 |
106 |
$3K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$520.00 |