| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,452 |
2,451 |
$105K |
| D0120 |
Periodic oral evaluation - established patient |
2,936 |
2,934 |
$79K |
| D1110 |
Prophylaxis - adult |
790 |
790 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,207 |
1,204 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
337 |
280 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,846 |
1,846 |
$26K |
| D0274 |
Bitewings - four radiographic images |
780 |
779 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
195 |
195 |
$6K |
| D0272 |
Bitewings - two radiographic images |
300 |
299 |
$5K |