| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
206 |
91 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
218 |
208 |
$14K |
| D1351 |
Sealant - per tooth |
302 |
84 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
219 |
207 |
$7K |
| D1120 |
Prophylaxis - child |
170 |
153 |
$5K |
| D1110 |
Prophylaxis - adult |
103 |
101 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
278 |
260 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
99 |
87 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
17 |
16 |
$461.60 |
| D0220 |
Intraoral - periapical first radiographic image |
32 |
30 |
$351.68 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$346.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
30 |
$322.28 |
| D0603 |
|
375 |
354 |
$0.00 |