| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,081 |
1,052 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,583 |
1,541 |
$21K |
| D0274 |
Bitewings - four radiographic images |
55 |
52 |
$965.22 |
| D1120 |
Prophylaxis - child |
40 |
39 |
$825.16 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
12 |
$683.83 |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$388.33 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$226.76 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
12 |
$140.79 |