| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,084 |
653 |
$237K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,333 |
847 |
$234K |
| D1120 |
Prophylaxis - child |
4,974 |
4,778 |
$112K |
| D0120 |
Periodic oral evaluation - established patient |
5,181 |
5,035 |
$78K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
817 |
370 |
$72K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,639 |
5,436 |
$63K |
| D7140 |
Extraction, erupted tooth or exposed root |
868 |
434 |
$46K |
| D0240 |
|
1,821 |
967 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
1,253 |
1,185 |
$34K |
| D0272 |
Bitewings - two radiographic images |
2,395 |
2,299 |
$32K |
| D1110 |
Prophylaxis - adult |
860 |
851 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,011 |
914 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
609 |
541 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,144 |
1,081 |
$14K |
| D1351 |
Sealant - per tooth |
653 |
233 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
73 |
38 |
$7K |
| D1510 |
|
57 |
37 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
89 |
53 |
$4K |
| D9310 |
|
83 |
81 |
$4K |
| D0330 |
Panoramic radiographic image |
143 |
143 |
$4K |
| D0274 |
Bitewings - four radiographic images |
122 |
122 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
207 |
84 |
$2K |