| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
219 |
219 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
234 |
234 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
74 |
66 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
174 |
174 |
$5K |
| D1351 |
Sealant - per tooth |
29 |
29 |
$4K |
| D0274 |
Bitewings - four radiographic images |
74 |
74 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
221 |
215 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
51 |
51 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
65 |
64 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
160 |
159 |
$940.80 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
16 |
$764.40 |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$725.70 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$327.60 |