| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,260 |
1,260 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,333 |
1,333 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
387 |
260 |
$26K |
| D1206 |
Topical application of fluoride varnish |
531 |
531 |
$15K |
| D0272 |
Bitewings - two radiographic images |
943 |
942 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
837 |
837 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
174 |
112 |
$8K |
| D1110 |
Prophylaxis - adult |
136 |
136 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
502 |
500 |
$7K |
| D1351 |
Sealant - per tooth |
135 |
42 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
43 |
12 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
42 |
26 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
66 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
251 |
251 |
$2K |
| D0274 |
Bitewings - four radiographic images |
60 |
60 |
$1K |
| D1330 |
|
1,113 |
1,113 |
$0.00 |
| D0603 |
|
592 |
592 |
$0.00 |
| D0602 |
|
440 |
440 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
177 |
169 |
$0.00 |
| D1999 |
|
44 |
43 |
$0.00 |