| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,964 |
1,964 |
$84K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
629 |
200 |
$73K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
802 |
493 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
2,067 |
2,067 |
$56K |
| D1206 |
Topical application of fluoride varnish |
1,846 |
1,846 |
$55K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
673 |
473 |
$34K |
| D7140 |
Extraction, erupted tooth or exposed root |
556 |
277 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
757 |
713 |
$23K |
| D1351 |
Sealant - per tooth |
547 |
276 |
$22K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
216 |
95 |
$19K |
| D1110 |
Prophylaxis - adult |
209 |
209 |
$11K |
| D0272 |
Bitewings - two radiographic images |
680 |
680 |
$11K |
| D0330 |
Panoramic radiographic image |
176 |
176 |
$7K |
| D0274 |
Bitewings - four radiographic images |
235 |
235 |
$6K |
| D2331 |
|
57 |
38 |
$5K |
| D9420 |
|
55 |
55 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
325 |
321 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
274 |
274 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
14 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
37 |
$1K |
| D9310 |
|
12 |
12 |
$981.36 |
| D9110 |
|
29 |
29 |
$792.28 |
| D1354 |
|
34 |
14 |
$510.30 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$360.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$168.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$111.86 |
| D1999 |
|
28 |
27 |
$0.00 |