| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,645 |
1,644 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
1,966 |
1,964 |
$50K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,075 |
1,074 |
$23K |
| D1110 |
Prophylaxis - adult |
364 |
364 |
$18K |
| D0274 |
Bitewings - four radiographic images |
380 |
380 |
$12K |
| D1206 |
Topical application of fluoride varnish |
354 |
354 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
24 |
$915.00 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$588.98 |