| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
236 |
236 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
76 |
44 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
55 |
55 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
69 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
507 |
429 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
49 |
49 |
$601.73 |
| D1330 |
|
302 |
301 |
$469.66 |
| D1208 |
Topical application of fluoride, excluding varnish |
288 |
287 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
437 |
433 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
81 |
81 |
$0.00 |