| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
313 |
313 |
$7K |
| D1110 |
Prophylaxis - adult |
202 |
202 |
$7K |
| D1206 |
Topical application of fluoride varnish |
300 |
289 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
281 |
281 |
$6K |
| D0274 |
Bitewings - four radiographic images |
255 |
255 |
$5K |
| D1999 |
|
335 |
278 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
17 |
$2K |
| D1120 |
Prophylaxis - child |
58 |
58 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
91 |
91 |
$553.56 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$189.42 |