| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,706 |
1,683 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,295 |
1,277 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
1,081 |
1,070 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
543 |
535 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
105 |
29 |
$11K |
| D0330 |
Panoramic radiographic image |
228 |
228 |
$10K |
| D0240 |
|
536 |
279 |
$6K |
| D1354 |
|
357 |
146 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
78 |
25 |
$5K |
| D0272 |
Bitewings - two radiographic images |
458 |
452 |
$4K |
| D1206 |
Topical application of fluoride varnish |
274 |
274 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
70 |
29 |
$4K |
| D1351 |
Sealant - per tooth |
45 |
13 |
$990.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$293.54 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$65.00 |