| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,291 |
1,290 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
1,341 |
1,340 |
$39K |
| D0274 |
Bitewings - four radiographic images |
859 |
858 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,653 |
1,615 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
178 |
121 |
$16K |
| D1120 |
Prophylaxis - child |
195 |
195 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,073 |
1,065 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
123 |
123 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
189 |
189 |
$6K |
| D0272 |
Bitewings - two radiographic images |
153 |
153 |
$3K |
| D1206 |
Topical application of fluoride varnish |
87 |
87 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
169 |
169 |
$3K |
| D0330 |
Panoramic radiographic image |
82 |
82 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
130 |
130 |
$2K |
| D1351 |
Sealant - per tooth |
23 |
12 |
$1K |