| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
462 |
449 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
143 |
38 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
208 |
200 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
310 |
276 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
269 |
264 |
$3K |
| D0330 |
Panoramic radiographic image |
47 |
41 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
59 |
40 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
28 |
$410.23 |
| D9994 |
|
31 |
25 |
$256.68 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$0.00 |
| D9920 |
|
12 |
12 |
$0.00 |