| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,466 |
1,462 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
1,368 |
1,363 |
$34K |
| D1206 |
Topical application of fluoride varnish |
1,043 |
1,036 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
220 |
158 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
302 |
301 |
$13K |
| D0274 |
Bitewings - four radiographic images |
1,018 |
1,014 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
417 |
416 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,168 |
1,160 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
1,298 |
1,288 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
65 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
94 |
94 |
$4K |
| D0330 |
Panoramic radiographic image |
43 |
43 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
58 |
$1K |