| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
996 |
971 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,768 |
1,711 |
$44K |
| D1110 |
Prophylaxis - adult |
986 |
950 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
400 |
248 |
$24K |
| D0274 |
Bitewings - four radiographic images |
824 |
794 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,195 |
1,153 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
318 |
166 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
288 |
287 |
$7K |
| D1206 |
Topical application of fluoride varnish |
416 |
409 |
$6K |
| D0330 |
Panoramic radiographic image |
126 |
125 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
346 |
332 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
263 |
131 |
$2K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$185.64 |