| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
519 |
519 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
682 |
682 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
219 |
180 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
488 |
488 |
$13K |
| D0274 |
Bitewings - four radiographic images |
454 |
452 |
$9K |
| D1110 |
Prophylaxis - adult |
175 |
175 |
$8K |
| D1351 |
Sealant - per tooth |
95 |
74 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
237 |
236 |
$6K |
| D0330 |
Panoramic radiographic image |
183 |
183 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
29 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
14 |
13 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
37 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
282 |
280 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
197 |
196 |
$2K |
| D0272 |
Bitewings - two radiographic images |
135 |
135 |
$1K |
| D9110 |
|
15 |
15 |
$825.00 |