| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
102 |
66 |
$5K |
| D1120 |
Prophylaxis - child |
172 |
171 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
214 |
213 |
$3K |
| D1110 |
Prophylaxis - adult |
92 |
91 |
$3K |
| D0274 |
Bitewings - four radiographic images |
112 |
111 |
$2K |
| D1351 |
Sealant - per tooth |
164 |
44 |
$2K |
| D0272 |
Bitewings - two radiographic images |
124 |
124 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
139 |
138 |
$1K |
| D1206 |
Topical application of fluoride varnish |
122 |
121 |
$918.75 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
16 |
$763.23 |
| D0220 |
Intraoral - periapical first radiographic image |
85 |
85 |
$527.52 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$459.16 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
27 |
27 |
$366.12 |
| D0230 |
Intraoral - periapical each additional radiographic image |
48 |
48 |
$287.98 |
| D0603 |
|
283 |
282 |
$0.00 |