| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
529 |
519 |
$22K |
| D1351 |
Sealant - per tooth |
1,027 |
184 |
$19K |
| D1206 |
Topical application of fluoride varnish |
420 |
416 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
370 |
362 |
$11K |
| D0274 |
Bitewings - four radiographic images |
399 |
393 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
524 |
512 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
460 |
449 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
28 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
149 |
147 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
113 |
85 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
51 |
48 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
22 |
15 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
15 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
16 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
102 |
98 |
$972.80 |
| D0272 |
Bitewings - two radiographic images |
49 |
47 |
$828.00 |