| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
15,089 |
14,152 |
$612K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,063 |
2,867 |
$456K |
| D0120 |
Periodic oral evaluation - established patient |
14,437 |
13,527 |
$400K |
| D1351 |
Sealant - per tooth |
7,017 |
3,818 |
$387K |
| D1208 |
Topical application of fluoride, excluding varnish |
13,533 |
12,726 |
$348K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,570 |
5,008 |
$206K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,168 |
2,429 |
$193K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18,661 |
12,749 |
$168K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,842 |
1,405 |
$125K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,847 |
1,378 |
$97K |
| D0220 |
Intraoral - periapical first radiographic image |
15,240 |
14,013 |
$89K |
| D1354 |
|
2,769 |
1,603 |
$77K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,336 |
1,036 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,880 |
1,730 |
$40K |
| D1510 |
|
515 |
438 |
$36K |
| D0140 |
Limited oral evaluation - problem focused |
1,479 |
1,402 |
$24K |
| D0274 |
Bitewings - four radiographic images |
892 |
862 |
$16K |
| D0272 |
Bitewings - two radiographic images |
784 |
713 |
$7K |
| D0330 |
Panoramic radiographic image |
161 |
158 |
$4K |
| D2330 |
|
76 |
72 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
62 |
60 |
$114.00 |