| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,744 |
2,743 |
$151K |
| D0210 |
Intraoral - complete series of radiographic images |
1,394 |
1,393 |
$82K |
| D0120 |
Periodic oral evaluation - established patient |
2,251 |
2,250 |
$62K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,180 |
1,180 |
$35K |
| D0272 |
Bitewings - two radiographic images |
1,172 |
1,172 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,082 |
1,081 |
$15K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
102 |
77 |
$12K |
| D0274 |
Bitewings - four radiographic images |
271 |
270 |
$8K |
| D0330 |
Panoramic radiographic image |
118 |
118 |
$5K |
| D1120 |
Prophylaxis - child |
58 |
58 |
$3K |
| D1351 |
Sealant - per tooth |
57 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$2K |
| D2331 |
|
13 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
126 |
126 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
70 |
70 |
$480.34 |