| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,723 |
1,723 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
2,157 |
2,156 |
$49K |
| D0274 |
Bitewings - four radiographic images |
1,918 |
1,918 |
$41K |
| D0220 |
Intraoral - periapical first radiographic image |
2,453 |
2,438 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,199 |
2,130 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
136 |
85 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
167 |
86 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
248 |
248 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
102 |
98 |
$1K |