| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,525 |
203 |
$26K |
| D1120 |
Prophylaxis - child |
571 |
552 |
$23K |
| D1206 |
Topical application of fluoride varnish |
600 |
544 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,033 |
487 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
364 |
354 |
$11K |
| D0330 |
Panoramic radiographic image |
268 |
266 |
$9K |
| D0274 |
Bitewings - four radiographic images |
391 |
384 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
471 |
463 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
72 |
28 |
$4K |
| D3120 |
|
204 |
57 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
135 |
131 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
173 |
139 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$742.68 |
| D0999 |
Unspecified diagnostic procedure, by report |
13 |
13 |
$390.00 |
| D0603 |
|
63 |
52 |
$262.50 |
| D9999 |
Unspecified adjunctive procedure, by report |
13 |
13 |
$260.00 |