| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,590 |
978 |
$111K |
| D1206 |
Topical application of fluoride varnish |
2,922 |
2,921 |
$91K |
| D1110 |
Prophylaxis - adult |
1,932 |
1,931 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
3,092 |
3,092 |
$77K |
| D1120 |
Prophylaxis - child |
1,459 |
1,459 |
$66K |
| D1351 |
Sealant - per tooth |
2,523 |
647 |
$50K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
507 |
366 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
667 |
442 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,956 |
1,956 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
380 |
379 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
2,959 |
2,957 |
$15K |
| D0603 |
|
1,412 |
1,411 |
$14K |
| D1353 |
|
1,400 |
311 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,772 |
2,772 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
405 |
397 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
306 |
306 |
$8K |
| D0272 |
Bitewings - two radiographic images |
620 |
620 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
57 |
57 |
$3K |
| D9920 |
|
12 |
12 |
$300.00 |
| D0601 |
|
25 |
25 |
$250.00 |