| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
247 |
247 |
$10K |
| D1206 |
Topical application of fluoride varnish |
582 |
582 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
423 |
423 |
$8K |
| D1120 |
Prophylaxis - child |
183 |
183 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
15 |
$4K |
| D0274 |
Bitewings - four radiographic images |
137 |
137 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
207 |
202 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
72 |
67 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
216 |
105 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$1K |