| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
21 |
12 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
103 |
67 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
100 |
99 |
$3K |
| D1110 |
Prophylaxis - adult |
73 |
72 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
15 |
$2K |
| D0330 |
Panoramic radiographic image |
42 |
42 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
38 |
$897.00 |
| D0274 |
Bitewings - four radiographic images |
40 |
39 |
$585.20 |
| D0220 |
Intraoral - periapical first radiographic image |
96 |
95 |
$570.11 |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
25 |
$548.03 |
| D0230 |
Intraoral - periapical each additional radiographic image |
88 |
86 |
$474.08 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$234.00 |