| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,963 |
421 |
$61K |
| D1120 |
Prophylaxis - child |
1,375 |
1,360 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,626 |
1,597 |
$41K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
735 |
726 |
$40K |
| D1206 |
Topical application of fluoride varnish |
1,521 |
1,491 |
$34K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
240 |
133 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
312 |
197 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
341 |
260 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
399 |
291 |
$24K |
| D1110 |
Prophylaxis - adult |
433 |
432 |
$19K |
| D0272 |
Bitewings - two radiographic images |
869 |
866 |
$17K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
166 |
95 |
$11K |
| D1330 |
|
1,497 |
1,495 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
361 |
360 |
$8K |
| D0274 |
Bitewings - four radiographic images |
218 |
218 |
$7K |
| D0330 |
Panoramic radiographic image |
165 |
164 |
$7K |
| D0603 |
|
660 |
659 |
$7K |
| D0602 |
|
411 |
411 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
138 |
138 |
$4K |
| D0240 |
|
166 |
126 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
275 |
271 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
82 |
78 |
$824.20 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$282.44 |