| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,933 |
1,887 |
$332.48 |
| D0120 |
Periodic oral evaluation - established patient |
2,082 |
2,043 |
$230.88 |
| D1208 |
Topical application of fluoride, excluding varnish |
990 |
946 |
$176.67 |
| D0272 |
Bitewings - two radiographic images |
982 |
961 |
$117.78 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,193 |
1,131 |
$115.40 |
| D0220 |
Intraoral - periapical first radiographic image |
1,649 |
1,602 |
$80.78 |
| D1999 |
|
2,893 |
2,603 |
$0.00 |
| D0330 |
Panoramic radiographic image |
143 |
139 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
187 |
186 |
$0.00 |
| D1110 |
Prophylaxis - adult |
156 |
154 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
25 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
29 |
27 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
61 |
14 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
1,196 |
1,187 |
$0.00 |
| D0603 |
|
1,012 |
927 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
121 |
66 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
97 |
89 |
$0.00 |
| D1351 |
Sealant - per tooth |
29 |
12 |
$0.00 |