| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
259 |
152 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
360 |
360 |
$10K |
| D1110 |
Prophylaxis - adult |
166 |
166 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
76 |
41 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
291 |
263 |
$3K |
| D0274 |
Bitewings - four radiographic images |
94 |
94 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
472 |
128 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$754.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$456.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$455.00 |