| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
920 |
920 |
$26K |
| D1120 |
Prophylaxis - child |
527 |
527 |
$19K |
| D1206 |
Topical application of fluoride varnish |
899 |
899 |
$13K |
| D1110 |
Prophylaxis - adult |
203 |
203 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
109 |
51 |
$8K |
| D0274 |
Bitewings - four radiographic images |
227 |
227 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
634 |
623 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
564 |
556 |
$6K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$2K |
| D1351 |
Sealant - per tooth |
36 |
12 |
$988.40 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$607.88 |
| D0602 |
|
82 |
82 |
$0.00 |
| D0601 |
|
600 |
599 |
$0.00 |