| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,221 |
1,193 |
$29K |
| D1206 |
Topical application of fluoride varnish |
2,349 |
2,220 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
507 |
295 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
85 |
25 |
$8K |
| D9310 |
|
991 |
937 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
320 |
319 |
$7K |
| D1354 |
|
11,000 |
1,472 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
91 |
50 |
$4K |
| D1351 |
Sealant - per tooth |
355 |
126 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
695 |
650 |
$3K |
| D0272 |
Bitewings - two radiographic images |
334 |
321 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
25 |
12 |
$1K |
| D0603 |
|
687 |
656 |
$1K |
| D1330 |
|
960 |
921 |
$920.00 |
| D9920 |
|
345 |
324 |
$770.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$420.00 |
| D0330 |
Panoramic radiographic image |
65 |
59 |
$364.00 |
| D0220 |
Intraoral - periapical first radiographic image |
45 |
45 |
$351.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
33 |
16 |
$207.00 |
| D1999 |
|
76 |
74 |
$203.00 |
| D0240 |
|
53 |
24 |
$128.00 |
| D1310 |
|
729 |
694 |
$10.00 |