| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,592 |
4,587 |
$316K |
| D0120 |
Periodic oral evaluation - established patient |
6,187 |
6,182 |
$214K |
| D1120 |
Prophylaxis - child |
2,320 |
2,320 |
$117K |
| D0274 |
Bitewings - four radiographic images |
2,777 |
2,774 |
$102K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,152 |
3,152 |
$64K |
| D0330 |
Panoramic radiographic image |
409 |
409 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
70 |
66 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
51 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$215.00 |
| D1999 |
|
209 |
198 |
$0.00 |