| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
476 |
317 |
$42K |
| D1120 |
Prophylaxis - child |
1,281 |
1,281 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,696 |
1,696 |
$34K |
| D1110 |
Prophylaxis - adult |
486 |
486 |
$21K |
| D1206 |
Topical application of fluoride varnish |
1,198 |
1,198 |
$17K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
427 |
388 |
$11K |
| D0330 |
Panoramic radiographic image |
240 |
240 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
657 |
657 |
$9K |
| D0274 |
Bitewings - four radiographic images |
216 |
216 |
$6K |
| D1351 |
Sealant - per tooth |
141 |
62 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
38 |
$3K |
| D0272 |
Bitewings - two radiographic images |
181 |
181 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
51 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
82 |
81 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
38 |
37 |
$1K |
| D3120 |
|
19 |
13 |
$551.95 |