| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
295 |
295 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
147 |
82 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
243 |
243 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
198 |
198 |
$5K |
| D0330 |
Panoramic radiographic image |
104 |
104 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
119 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
54 |
54 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
55 |
$2K |
| D0274 |
Bitewings - four radiographic images |
179 |
179 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
439 |
423 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
255 |
251 |
$1K |
| D1206 |
Topical application of fluoride varnish |
38 |
38 |
$1K |
| D0350 |
|
18 |
18 |
$90.00 |