| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,736 |
1,736 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
2,205 |
2,205 |
$50K |
| D1206 |
Topical application of fluoride varnish |
2,056 |
2,056 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,135 |
1,135 |
$31K |
| D0330 |
Panoramic radiographic image |
551 |
551 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
2,139 |
2,132 |
$27K |
| D1120 |
Prophylaxis - child |
654 |
654 |
$23K |
| D0272 |
Bitewings - two radiographic images |
857 |
857 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
449 |
449 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,159 |
1,120 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
188 |
188 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
28 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
14 |
$455.00 |