| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
105 |
104 |
$646.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
41 |
$639.00 |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
56 |
$464.00 |
| D0220 |
Intraoral - periapical first radiographic image |
151 |
123 |
$247.00 |
| D1206 |
Topical application of fluoride varnish |
67 |
67 |
$228.00 |
| D0274 |
Bitewings - four radiographic images |
45 |
45 |
$203.00 |
| D1110 |
Prophylaxis - adult |
34 |
34 |
$188.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
102 |
83 |
$180.00 |
| D0120 |
Periodic oral evaluation - established patient |
49 |
49 |
$168.00 |
| D0603 |
|
58 |
56 |
$0.00 |
| D4921 |
|
31 |
13 |
$0.00 |