| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,795 |
1,794 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
2,505 |
2,504 |
$65K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
368 |
239 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
425 |
259 |
$36K |
| D1120 |
Prophylaxis - child |
912 |
912 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,284 |
1,283 |
$30K |
| D0274 |
Bitewings - four radiographic images |
568 |
568 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
63 |
63 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
48 |
48 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
79 |
78 |
$1K |