| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
434 |
433 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
531 |
531 |
$12K |
| D0274 |
Bitewings - four radiographic images |
372 |
372 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
594 |
585 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$1K |
| D1120 |
Prophylaxis - child |
30 |
30 |
$997.50 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
13 |
$784.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$688.75 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$172.90 |
| D1330 |
|
110 |
110 |
$0.00 |
| D1999 |
|
62 |
61 |
$0.00 |