| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,074 |
2,074 |
$80K |
| D0120 |
Periodic oral evaluation - established patient |
2,127 |
2,127 |
$56K |
| D1351 |
Sealant - per tooth |
1,189 |
350 |
$48K |
| D1206 |
Topical application of fluoride varnish |
1,545 |
1,545 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
646 |
349 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,127 |
1,127 |
$31K |
| D1110 |
Prophylaxis - adult |
469 |
469 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,014 |
2,010 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,067 |
1,067 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,019 |
1,017 |
$12K |
| D0272 |
Bitewings - two radiographic images |
787 |
787 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
210 |
132 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
319 |
319 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
140 |
99 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
78 |
45 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
104 |
104 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
38 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
43 |
43 |
$452.10 |