| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,562 |
890 |
$258K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,383 |
1,131 |
$191K |
| D1120 |
Prophylaxis - child |
5,436 |
5,305 |
$104K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,112 |
5,944 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
4,542 |
4,425 |
$76K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,160 |
558 |
$73K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,280 |
2,214 |
$60K |
| D1351 |
Sealant - per tooth |
2,354 |
624 |
$50K |
| D0272 |
Bitewings - two radiographic images |
4,450 |
4,340 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
757 |
367 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,070 |
5,899 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
6,382 |
6,188 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
475 |
290 |
$24K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
916 |
872 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
764 |
736 |
$17K |
| D1110 |
Prophylaxis - adult |
328 |
307 |
$10K |
| D0274 |
Bitewings - four radiographic images |
300 |
279 |
$6K |
| D1510 |
|
33 |
25 |
$4K |
| D2335 |
|
37 |
15 |
$3K |
| D0330 |
Panoramic radiographic image |
66 |
65 |
$3K |
| D2140 |
|
24 |
13 |
$960.00 |
| D1999 |
|
236 |
232 |
$0.00 |