| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
520 |
511 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,003 |
980 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
561 |
544 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
464 |
464 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,352 |
1,217 |
$11K |
| D0274 |
Bitewings - four radiographic images |
579 |
566 |
$8K |
| D4341 |
|
221 |
64 |
$5K |
| D0330 |
Panoramic radiographic image |
207 |
203 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
92 |
41 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,304 |
805 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
163 |
159 |
$3K |
| D1999 |
|
274 |
216 |
$3K |
| D1120 |
Prophylaxis - child |
63 |
63 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
14 |
$1K |
| D1351 |
Sealant - per tooth |
41 |
12 |
$1K |
| D4910 |
|
13 |
13 |
$910.00 |