| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
113 |
47 |
$7K |
| D1110 |
Prophylaxis - adult |
161 |
158 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
196 |
193 |
$4K |
| D0274 |
Bitewings - four radiographic images |
136 |
135 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
181 |
179 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
61 |
61 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$993.20 |
| D0220 |
Intraoral - periapical first radiographic image |
120 |
117 |
$875.78 |
| D1206 |
Topical application of fluoride varnish |
38 |
38 |
$543.75 |
| D0230 |
Intraoral - periapical each additional radiographic image |
34 |
31 |
$155.97 |