| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,447 |
1,446 |
$33K |
| D1206 |
Topical application of fluoride varnish |
1,542 |
1,538 |
$33K |
| D1120 |
Prophylaxis - child |
1,019 |
1,018 |
$30K |
| D1110 |
Prophylaxis - adult |
501 |
501 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
206 |
152 |
$12K |
| D0274 |
Bitewings - four radiographic images |
378 |
378 |
$12K |
| D0272 |
Bitewings - two radiographic images |
567 |
564 |
$12K |
| D1330 |
|
1,172 |
1,172 |
$8K |
| D0603 |
|
762 |
762 |
$8K |
| D0330 |
Panoramic radiographic image |
144 |
144 |
$6K |
| D1351 |
Sealant - per tooth |
162 |
41 |
$5K |
| D1310 |
|
316 |
316 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
37 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
31 |
24 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
66 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
152 |
147 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
18 |
18 |
$521.00 |
| D0602 |
|
53 |
53 |
$520.00 |
| D0240 |
|
12 |
12 |
$271.32 |