| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
103 |
69 |
$17K |
| D1206 |
Topical application of fluoride varnish |
366 |
361 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
453 |
440 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
240 |
237 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
340 |
310 |
$8K |
| D1120 |
Prophylaxis - child |
163 |
160 |
$8K |
| D1351 |
Sealant - per tooth |
79 |
26 |
$3K |
| D0274 |
Bitewings - four radiographic images |
63 |
62 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
17 |
$3K |
| D1110 |
Prophylaxis - adult |
41 |
40 |
$3K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$434.00 |