| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
861 |
853 |
$24K |
| D1110 |
Prophylaxis - adult |
269 |
268 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
880 |
872 |
$13K |
| D1120 |
Prophylaxis - child |
297 |
294 |
$11K |
| D1351 |
Sealant - per tooth |
378 |
63 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
123 |
40 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
574 |
567 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
552 |
532 |
$6K |
| D0274 |
Bitewings - four radiographic images |
165 |
164 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
25 |
$5K |
| D0272 |
Bitewings - two radiographic images |
70 |
68 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$847.68 |
| D0603 |
|
135 |
129 |
$0.00 |
| D0601 |
|
505 |
500 |
$0.00 |
| D0602 |
|
204 |
201 |
$0.00 |