| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,116 |
624 |
$55K |
| D1351 |
Sealant - per tooth |
2,641 |
591 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
691 |
411 |
$27K |
| D1120 |
Prophylaxis - child |
1,288 |
1,285 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,544 |
1,543 |
$22K |
| D1110 |
Prophylaxis - adult |
785 |
784 |
$21K |
| D0274 |
Bitewings - four radiographic images |
929 |
927 |
$16K |
| D0145 |
Oral evaluation for a patient under three years of age |
200 |
200 |
$14K |
| D0272 |
Bitewings - two radiographic images |
935 |
933 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,297 |
1,296 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
557 |
552 |
$9K |
| D0330 |
Panoramic radiographic image |
398 |
397 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
450 |
406 |
$6K |
| D1206 |
Topical application of fluoride varnish |
737 |
735 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
657 |
651 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
590 |
566 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
17 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$112.68 |
| D0603 |
|
1,845 |
1,842 |
$0.00 |
| D0602 |
|
388 |
380 |
$0.00 |