| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
328 |
328 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
240 |
114 |
$16K |
| D1110 |
Prophylaxis - adult |
92 |
92 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
430 |
372 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
128 |
68 |
$7K |
| D1120 |
Prophylaxis - child |
167 |
166 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
41 |
41 |
$2K |
| D0274 |
Bitewings - four radiographic images |
87 |
87 |
$2K |
| D0272 |
Bitewings - two radiographic images |
150 |
150 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
34 |
34 |
$2K |
| D9430 |
|
28 |
28 |
$896.00 |
| D1206 |
Topical application of fluoride varnish |
54 |
54 |
$792.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
104 |
103 |
$726.25 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
27 |
$324.00 |