| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
783 |
155 |
$21K |
| D0145 |
Oral evaluation for a patient under three years of age |
147 |
140 |
$19K |
| D1120 |
Prophylaxis - child |
571 |
550 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,810 |
944 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
702 |
674 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
195 |
77 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
912 |
878 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,046 |
994 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
69 |
33 |
$5K |
| D0272 |
Bitewings - two radiographic images |
180 |
172 |
$4K |
| D0274 |
Bitewings - four radiographic images |
74 |
74 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
79 |
71 |
$2K |
| D1110 |
Prophylaxis - adult |
42 |
42 |
$2K |
| D1330 |
|
120 |
120 |
$23.28 |
| D0601 |
|
912 |
896 |
$0.00 |
| D0603 |
|
244 |
239 |
$0.00 |
| D0602 |
|
38 |
36 |
$0.00 |