| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,872 |
1,870 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
1,880 |
1,880 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
518 |
355 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,945 |
1,945 |
$27K |
| D1351 |
Sealant - per tooth |
339 |
106 |
$14K |
| D0272 |
Bitewings - two radiographic images |
819 |
816 |
$13K |
| D1110 |
Prophylaxis - adult |
187 |
187 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
234 |
234 |
$6K |
| D1206 |
Topical application of fluoride varnish |
206 |
206 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
71 |
45 |
$4K |
| D0274 |
Bitewings - four radiographic images |
119 |
119 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
245 |
245 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
24 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
13 |
12 |
$2K |
| D0240 |
|
32 |
32 |
$807.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
83 |
83 |
$625.33 |