| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,251 |
1,251 |
$44K |
| D0274 |
Bitewings - four radiographic images |
745 |
745 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
521 |
521 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
997 |
997 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
436 |
436 |
$11K |
| D1351 |
Sealant - per tooth |
240 |
69 |
$9K |
| D1206 |
Topical application of fluoride varnish |
245 |
245 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
14 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
17 |
17 |
$219.85 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
16 |
$149.54 |
| D1330 |
|
562 |
562 |
$0.00 |
| D9215 |
|
45 |
38 |
$0.00 |