| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
193 |
162 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
194 |
163 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
171 |
140 |
$5K |
| D0274 |
Bitewings - four radiographic images |
103 |
84 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
166 |
135 |
$916.60 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
12 |
$866.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
158 |
130 |
$589.00 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
14 |
$105.80 |