| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
196 |
84 |
$11K |
| D1110 |
Prophylaxis - adult |
289 |
289 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
509 |
509 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
374 |
374 |
$6K |
| D1120 |
Prophylaxis - child |
181 |
181 |
$4K |
| D0274 |
Bitewings - four radiographic images |
147 |
147 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
83 |
79 |
$2K |
| D0272 |
Bitewings - two radiographic images |
94 |
94 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$368.90 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$135.00 |