| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,234 |
5,234 |
$164K |
| D0120 |
Periodic oral evaluation - established patient |
5,103 |
5,102 |
$109K |
| D1351 |
Sealant - per tooth |
1,356 |
675 |
$72K |
| D1206 |
Topical application of fluoride varnish |
2,242 |
2,242 |
$50K |
| D0272 |
Bitewings - two radiographic images |
4,034 |
4,033 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
755 |
657 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,325 |
3,321 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
513 |
447 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
392 |
340 |
$16K |
| D1110 |
Prophylaxis - adult |
395 |
395 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
658 |
658 |
$14K |
| D0330 |
Panoramic radiographic image |
442 |
442 |
$13K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
75 |
71 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
39 |
38 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
140 |
137 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$638.34 |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
31 |
$295.46 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$245.96 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
16 |
$118.40 |
| D1999 |
|
904 |
878 |
$0.00 |