| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,067 |
356 |
$321.26 |
| D1120 |
Prophylaxis - child |
7,254 |
6,897 |
$216.00 |
| D0120 |
Periodic oral evaluation - established patient |
7,982 |
7,581 |
$125.00 |
| D0272 |
Bitewings - two radiographic images |
5,908 |
5,566 |
$102.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
607 |
139 |
$95.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
8,923 |
8,464 |
$85.00 |
| D0220 |
Intraoral - periapical first radiographic image |
8,828 |
8,255 |
$60.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,391 |
7,846 |
$60.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
828 |
755 |
$53.75 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
604 |
579 |
$28.00 |
| D0274 |
Bitewings - four radiographic images |
1,497 |
1,427 |
$0.00 |
| D1110 |
Prophylaxis - adult |
1,590 |
1,509 |
$0.00 |
| D1999 |
|
4,090 |
3,309 |
$0.00 |
| D0330 |
Panoramic radiographic image |
526 |
494 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
130 |
50 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,014 |
1,126 |
$0.00 |
| D9248 |
|
128 |
112 |
$0.00 |
| D0240 |
|
397 |
156 |
$0.00 |
| D1351 |
Sealant - per tooth |
1,040 |
320 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
375 |
345 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
260 |
130 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
51 |
51 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
98 |
93 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
136 |
35 |
$0.00 |