| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
479 |
361 |
$52K |
| D1120 |
Prophylaxis - child |
1,153 |
1,153 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
1,092 |
1,092 |
$49K |
| D1206 |
Topical application of fluoride varnish |
1,114 |
1,114 |
$35K |
| D0272 |
Bitewings - two radiographic images |
877 |
877 |
$29K |
| D1351 |
Sealant - per tooth |
360 |
106 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
328 |
323 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
48 |
$5K |
| D0603 |
|
540 |
540 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
151 |
150 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$540.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$408.00 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$342.00 |