| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
345 |
344 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
107 |
41 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
201 |
200 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
212 |
205 |
$10K |
| D1206 |
Topical application of fluoride varnish |
288 |
287 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
216 |
216 |
$7K |
| D0274 |
Bitewings - four radiographic images |
218 |
217 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
253 |
247 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
99 |
99 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$164.00 |
| D1330 |
|
15 |
15 |
$90.00 |