| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
465 |
456 |
$4K |
| D0274 |
Bitewings - four radiographic images |
277 |
277 |
$3K |
| D1110 |
Prophylaxis - adult |
91 |
91 |
$3K |
| D0330 |
Panoramic radiographic image |
207 |
207 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
131 |
131 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
89 |
89 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
68 |
67 |
$303.78 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
14 |
$195.90 |