| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
709 |
709 |
$30K |
| D1206 |
Topical application of fluoride varnish |
672 |
672 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
604 |
604 |
$18K |
| D1351 |
Sealant - per tooth |
91 |
82 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
77 |
71 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
134 |
127 |
$5K |
| D0274 |
Bitewings - four radiographic images |
125 |
125 |
$2K |
| D0272 |
Bitewings - two radiographic images |
153 |
153 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
62 |
62 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
14 |
$618.80 |
| D0220 |
Intraoral - periapical first radiographic image |
48 |
48 |
$317.28 |
| D0140 |
Limited oral evaluation - problem focused |
19 |
19 |
$305.92 |