| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
964 |
961 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,077 |
1,071 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,198 |
1,195 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
138 |
73 |
$16K |
| D1110 |
Prophylaxis - adult |
164 |
163 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
463 |
451 |
$7K |
| D2740 |
Crown - porcelain/ceramic |
12 |
12 |
$7K |
| D0240 |
|
275 |
138 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
589 |
391 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
79 |
79 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
84 |
84 |
$3K |
| D0272 |
Bitewings - two radiographic images |
132 |
132 |
$3K |
| D0274 |
Bitewings - four radiographic images |
77 |
77 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
14 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$1K |