| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,121 |
1,110 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
1,204 |
1,202 |
$31K |
| D1120 |
Prophylaxis - child |
616 |
616 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
184 |
116 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,363 |
1,317 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
696 |
696 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,672 |
969 |
$14K |
| D0274 |
Bitewings - four radiographic images |
334 |
333 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
168 |
167 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
25 |
$5K |
| D0330 |
Panoramic radiographic image |
77 |
77 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
67 |
67 |
$3K |