| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
12,688 |
12,594 |
$530K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,826 |
2,216 |
$356K |
| D0120 |
Periodic oral evaluation - established patient |
11,866 |
11,779 |
$339K |
| D1208 |
Topical application of fluoride, excluding varnish |
12,574 |
12,480 |
$333K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,367 |
4,123 |
$265K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,203 |
1,878 |
$139K |
| D1351 |
Sealant - per tooth |
1,808 |
969 |
$113K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,517 |
1,240 |
$86K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,876 |
10,548 |
$80K |
| D0220 |
Intraoral - periapical first radiographic image |
11,883 |
11,709 |
$78K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,300 |
2,291 |
$58K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,239 |
1,113 |
$50K |
| D1354 |
|
2,090 |
1,150 |
$49K |
| D0274 |
Bitewings - four radiographic images |
2,068 |
2,047 |
$40K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
506 |
462 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
1,311 |
1,276 |
$25K |
| D1510 |
|
284 |
261 |
$20K |
| D0330 |
Panoramic radiographic image |
530 |
502 |
$14K |
| D0272 |
Bitewings - two radiographic images |
1,301 |
1,286 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
42 |
42 |
$3K |
| D2330 |
|
16 |
13 |
$834.88 |