| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,918 |
1,918 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
2,373 |
2,373 |
$65K |
| D1351 |
Sealant - per tooth |
1,961 |
245 |
$58K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,132 |
2,132 |
$49K |
| D1110 |
Prophylaxis - adult |
424 |
424 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
67 |
39 |
$8K |
| D0274 |
Bitewings - four radiographic images |
165 |
165 |
$5K |
| D0330 |
Panoramic radiographic image |
58 |
58 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
27 |
$4K |
| D0272 |
Bitewings - two radiographic images |
91 |
91 |
$2K |