| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,391 |
2,354 |
$91K |
| D0120 |
Periodic oral evaluation - established patient |
2,566 |
2,528 |
$68K |
| D1206 |
Topical application of fluoride varnish |
2,794 |
2,752 |
$67K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
485 |
295 |
$58K |
| D1110 |
Prophylaxis - adult |
857 |
842 |
$41K |
| D0272 |
Bitewings - two radiographic images |
518 |
514 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
41 |
$5K |
| D0274 |
Bitewings - four radiographic images |
159 |
154 |
$5K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$1K |
| D1351 |
Sealant - per tooth |
33 |
13 |
$957.00 |