| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
259 |
255 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
208 |
198 |
$4K |
| D0274 |
Bitewings - four radiographic images |
237 |
228 |
$4K |
| D1351 |
Sealant - per tooth |
138 |
12 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
580 |
260 |
$3K |
| D1206 |
Topical application of fluoride varnish |
135 |
128 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
342 |
323 |
$2K |
| D1330 |
|
94 |
91 |
$825.30 |
| D0140 |
Limited oral evaluation - problem focused |
29 |
28 |
$660.89 |
| D0120 |
Periodic oral evaluation - established patient |
110 |
110 |
$655.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
12 |
$0.00 |
| D0330 |
Panoramic radiographic image |
30 |
30 |
$0.00 |