| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
320 |
130 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
356 |
351 |
$9K |
| D1110 |
Prophylaxis - adult |
149 |
149 |
$7K |
| D0274 |
Bitewings - four radiographic images |
212 |
208 |
$6K |
| D1120 |
Prophylaxis - child |
191 |
185 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
389 |
382 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
519 |
503 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
189 |
169 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
467 |
452 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
26 |
26 |
$3K |
| D0272 |
Bitewings - two radiographic images |
90 |
86 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
30 |
$1K |
| D0330 |
Panoramic radiographic image |
16 |
15 |
$574.42 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$176.40 |
| D0602 |
|
363 |
357 |
$0.00 |
| D0603 |
|
179 |
175 |
$0.00 |