| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,753 |
3,753 |
$111K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,762 |
1,377 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
4,266 |
4,266 |
$64K |
| D0274 |
Bitewings - four radiographic images |
4,013 |
4,013 |
$56K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
792 |
650 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,276 |
2,276 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
4,513 |
4,482 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,333 |
4,326 |
$18K |
| D1120 |
Prophylaxis - child |
478 |
478 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
287 |
284 |
$4K |
| D1351 |
Sealant - per tooth |
82 |
27 |
$1K |
| D0270 |
|
307 |
304 |
$1K |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$200.00 |