| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,281 |
1,278 |
$57K |
| D1206 |
Topical application of fluoride varnish |
1,265 |
1,262 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
543 |
341 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,108 |
1,108 |
$27K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
114 |
97 |
$11K |
| D0272 |
Bitewings - two radiographic images |
1,044 |
1,044 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
163 |
118 |
$9K |
| D0240 |
|
471 |
468 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
187 |
185 |
$4K |
| D0603 |
|
458 |
458 |
$4K |
| D9920 |
|
189 |
181 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
378 |
377 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
59 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
34 |
34 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
247 |
247 |
$1K |
| D1351 |
Sealant - per tooth |
54 |
26 |
$1K |