| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,955 |
1,947 |
$83K |
| D1206 |
Topical application of fluoride varnish |
1,806 |
1,798 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,695 |
1,689 |
$41K |
| D0272 |
Bitewings - two radiographic images |
1,088 |
1,084 |
$19K |
| D0274 |
Bitewings - four radiographic images |
374 |
374 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
215 |
205 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
405 |
405 |
$5K |
| D1110 |
Prophylaxis - adult |
91 |
91 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
21 |
12 |
$4K |
| D1351 |
Sealant - per tooth |
130 |
39 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
13 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
80 |
80 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
14 |
$2K |
| D0603 |
|
98 |
97 |
$970.13 |
| D0220 |
Intraoral - periapical first radiographic image |
94 |
94 |
$821.04 |
| D0145 |
Oral evaluation for a patient under three years of age |
16 |
16 |
$720.00 |
| D0602 |
|
48 |
48 |
$480.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
28 |
$404.94 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$285.49 |
| D0601 |
|
21 |
21 |
$210.00 |