| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,335 |
1,335 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
1,695 |
1,695 |
$38K |
| D0274 |
Bitewings - four radiographic images |
682 |
682 |
$18K |
| D1206 |
Topical application of fluoride varnish |
963 |
963 |
$16K |
| D1120 |
Prophylaxis - child |
328 |
328 |
$11K |
| D0272 |
Bitewings - two radiographic images |
501 |
501 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
728 |
713 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
367 |
367 |
$6K |
| D0330 |
Panoramic radiographic image |
116 |
116 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
128 |
128 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
37 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
110 |
110 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
89 |
75 |
$853.46 |