| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
530 |
512 |
$23K |
| D1206 |
Topical application of fluoride varnish |
1,249 |
1,211 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
943 |
916 |
$19K |
| D1120 |
Prophylaxis - child |
622 |
605 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,032 |
993 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
75 |
53 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
937 |
771 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
111 |
54 |
$6K |
| D0330 |
Panoramic radiographic image |
128 |
122 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
195 |
185 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
220 |
200 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
211 |
208 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
40 |
12 |
$5K |
| D0274 |
Bitewings - four radiographic images |
173 |
173 |
$5K |
| D0272 |
Bitewings - two radiographic images |
200 |
192 |
$3K |
| D1351 |
Sealant - per tooth |
44 |
12 |
$1K |
| D0603 |
|
104 |
104 |
$850.95 |
| D0602 |
|
24 |
24 |
$194.44 |