| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,096 |
2,160 |
$430K |
| D1120 |
Prophylaxis - child |
10,498 |
10,220 |
$425K |
| D1208 |
Topical application of fluoride, excluding varnish |
10,284 |
10,017 |
$264K |
| D0120 |
Periodic oral evaluation - established patient |
9,251 |
8,997 |
$255K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,968 |
3,098 |
$220K |
| D1351 |
Sealant - per tooth |
2,673 |
1,347 |
$184K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,948 |
1,519 |
$128K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,527 |
1,216 |
$110K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,327 |
4,169 |
$96K |
| D2140 |
|
2,030 |
1,547 |
$92K |
| D0274 |
Bitewings - four radiographic images |
3,556 |
3,416 |
$62K |
| D0272 |
Bitewings - two radiographic images |
5,251 |
5,091 |
$52K |
| D0220 |
Intraoral - periapical first radiographic image |
8,403 |
8,108 |
$50K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,610 |
6,124 |
$33K |
| D1110 |
Prophylaxis - adult |
860 |
825 |
$31K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
425 |
354 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
1,378 |
1,324 |
$22K |
| D9110 |
|
137 |
137 |
$7K |
| D2740 |
Crown - porcelain/ceramic |
12 |
12 |
$3K |
| D1206 |
Topical application of fluoride varnish |
22 |
22 |
$572.00 |
| D9310 |
|
12 |
12 |
$205.20 |