| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,907 |
5,150 |
$230K |
| D1351 |
Sealant - per tooth |
6,958 |
1,006 |
$215K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,815 |
910 |
$210K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,818 |
767 |
$174K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,684 |
6,780 |
$153K |
| D0120 |
Periodic oral evaluation - established patient |
6,307 |
5,504 |
$152K |
| D1110 |
Prophylaxis - adult |
2,773 |
2,454 |
$147K |
| D0330 |
Panoramic radiographic image |
1,252 |
1,081 |
$83K |
| D0274 |
Bitewings - four radiographic images |
2,031 |
1,772 |
$73K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,038 |
1,781 |
$72K |
| D0272 |
Bitewings - two radiographic images |
1,786 |
1,675 |
$47K |
| D2330 |
|
253 |
127 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
203 |
178 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
18 |
13 |
$247.50 |