| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
181 |
178 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
24 |
$4K |
| D1351 |
Sealant - per tooth |
155 |
28 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
13 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
183 |
180 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
218 |
175 |
$2K |
| D0274 |
Bitewings - four radiographic images |
74 |
72 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
184 |
182 |
$2K |
| D1110 |
Prophylaxis - adult |
42 |
40 |
$2K |
| D1120 |
Prophylaxis - child |
56 |
56 |
$2K |
| D0603 |
|
36 |
36 |
$0.00 |
| D0602 |
|
30 |
30 |
$0.00 |