| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1208 |
Topical application of fluoride, excluding varnish |
611 |
588 |
$12K |
| D1110 |
Prophylaxis - adult |
348 |
344 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
496 |
492 |
$11K |
| D1120 |
Prophylaxis - child |
302 |
301 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
227 |
224 |
$5K |
| D0274 |
Bitewings - four radiographic images |
269 |
268 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
76 |
76 |
$936.00 |
| D4355 |
|
12 |
12 |
$552.00 |