| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
539 |
534 |
$20K |
| D1351 |
Sealant - per tooth |
548 |
107 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
623 |
619 |
$13K |
| D1120 |
Prophylaxis - child |
276 |
276 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
99 |
68 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
351 |
351 |
$5K |
| D0272 |
Bitewings - two radiographic images |
297 |
295 |
$5K |
| D0330 |
Panoramic radiographic image |
122 |
120 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
214 |
212 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
14 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$708.50 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$364.39 |