| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
131 |
59 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
26 |
$5K |
| D1110 |
Prophylaxis - adult |
115 |
105 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
114 |
106 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
54 |
51 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
60 |
56 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
86 |
83 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
24 |
24 |
$525.12 |
| D0274 |
Bitewings - four radiographic images |
17 |
16 |
$483.14 |