| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
440 |
440 |
$10K |
| D1110 |
Prophylaxis - adult |
186 |
186 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
105 |
76 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
95 |
71 |
$4K |
| D1120 |
Prophylaxis - child |
108 |
108 |
$3K |
| D0272 |
Bitewings - two radiographic images |
72 |
72 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
63 |
$950.00 |
| D0220 |
Intraoral - periapical first radiographic image |
186 |
180 |
$897.00 |
| D1206 |
Topical application of fluoride varnish |
119 |
119 |
$893.00 |
| D0274 |
Bitewings - four radiographic images |
99 |
98 |
$806.50 |
| D0140 |
Limited oral evaluation - problem focused |
60 |
59 |
$630.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
160 |
124 |
$477.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$266.00 |
| D1999 |
|
22 |
21 |
$140.00 |
| D1330 |
|
158 |
158 |
$0.01 |
| D9986 |
|
89 |
89 |
$0.00 |