| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,569 |
1,562 |
$66K |
| D1351 |
Sealant - per tooth |
653 |
433 |
$52K |
| D1206 |
Topical application of fluoride varnish |
1,525 |
1,518 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,271 |
1,264 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
334 |
272 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
271 |
271 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
834 |
831 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
68 |
60 |
$4K |
| D0274 |
Bitewings - four radiographic images |
233 |
232 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
755 |
740 |
$4K |
| D0272 |
Bitewings - two radiographic images |
324 |
323 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
79 |
67 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
84 |
83 |
$1K |