| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,512 |
1,512 |
$82K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
671 |
576 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
1,977 |
1,977 |
$54K |
| D1120 |
Prophylaxis - child |
1,089 |
1,089 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,170 |
1,170 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,086 |
1,086 |
$32K |
| D0330 |
Panoramic radiographic image |
978 |
978 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
412 |
353 |
$28K |
| D2740 |
Crown - porcelain/ceramic |
44 |
39 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,457 |
1,457 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
580 |
580 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
435 |
430 |
$6K |
| D0272 |
Bitewings - two radiographic images |
55 |
55 |
$923.18 |
| D0230 |
Intraoral - periapical each additional radiographic image |
28 |
28 |
$388.22 |