| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,925 |
1,925 |
$84K |
| D1206 |
Topical application of fluoride varnish |
2,049 |
2,046 |
$63K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
947 |
525 |
$62K |
| D1351 |
Sealant - per tooth |
2,902 |
736 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
1,804 |
1,804 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
545 |
315 |
$28K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
936 |
877 |
$23K |
| D1353 |
|
1,884 |
412 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
107 |
62 |
$11K |
| D0272 |
Bitewings - two radiographic images |
847 |
847 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
85 |
69 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
109 |
60 |
$7K |
| D1110 |
Prophylaxis - adult |
186 |
186 |
$7K |
| D0603 |
|
886 |
886 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,375 |
1,374 |
$6K |
| D0274 |
Bitewings - four radiographic images |
523 |
523 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
91 |
91 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,150 |
1,149 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
121 |
121 |
$3K |
| D0601 |
|
349 |
349 |
$3K |
| D0602 |
|
140 |
140 |
$1K |