| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,823 |
1,727 |
$65K |
| D1206 |
Topical application of fluoride varnish |
1,876 |
1,773 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,916 |
1,215 |
$28K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
215 |
69 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
759 |
682 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
875 |
858 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
273 |
143 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,054 |
991 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,595 |
1,386 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
414 |
376 |
$9K |
| D0330 |
Panoramic radiographic image |
233 |
211 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
96 |
44 |
$7K |
| D1351 |
Sealant - per tooth |
122 |
50 |
$3K |
| D1354 |
|
84 |
16 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
19 |
13 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
24 |
24 |
$711.16 |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$647.10 |
| D0603 |
|
1,829 |
1,683 |
$0.00 |
| D1330 |
|
1,170 |
1,121 |
$0.00 |