| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,850 |
1,850 |
$67K |
| D1206 |
Topical application of fluoride varnish |
1,930 |
1,930 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,475 |
1,475 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
577 |
342 |
$31K |
| D0272 |
Bitewings - two radiographic images |
1,311 |
1,311 |
$15K |
| D1351 |
Sealant - per tooth |
512 |
169 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
170 |
112 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
253 |
244 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
299 |
299 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
86 |
69 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
607 |
604 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
75 |
62 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
61 |
50 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
94 |
72 |
$3K |
| D2332 |
|
40 |
35 |
$3K |
| D9310 |
|
43 |
43 |
$2K |
| D2331 |
|
36 |
26 |
$2K |
| D0330 |
Panoramic radiographic image |
58 |
58 |
$2K |
| D0603 |
|
115 |
115 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
266 |
266 |
$849.00 |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$801.02 |
| D1110 |
Prophylaxis - adult |
17 |
17 |
$694.45 |
| D7111 |
|
30 |
24 |
$679.20 |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
30 |
$476.58 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$288.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
25 |
$273.40 |
| D0601 |
|
13 |
13 |
$130.00 |
| D0602 |
|
12 |
12 |
$120.00 |