| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,170 |
1,107 |
$167K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,297 |
524 |
$156K |
| D1120 |
Prophylaxis - child |
3,829 |
3,778 |
$99K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,135 |
2,107 |
$90K |
| D0120 |
Periodic oral evaluation - established patient |
2,828 |
2,798 |
$82K |
| D1206 |
Topical application of fluoride varnish |
4,779 |
4,722 |
$72K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
976 |
603 |
$64K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,485 |
3,120 |
$64K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
734 |
316 |
$55K |
| D7140 |
Extraction, erupted tooth or exposed root |
834 |
458 |
$49K |
| D0220 |
Intraoral - periapical first radiographic image |
3,710 |
3,632 |
$41K |
| D1351 |
Sealant - per tooth |
1,686 |
494 |
$39K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,226 |
1,151 |
$31K |
| D1110 |
Prophylaxis - adult |
875 |
872 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,588 |
1,568 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
314 |
311 |
$15K |
| D0274 |
Bitewings - four radiographic images |
589 |
585 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
365 |
361 |
$11K |
| D9310 |
|
108 |
106 |
$5K |
| D2330 |
|
63 |
29 |
$4K |
| D0330 |
Panoramic radiographic image |
80 |
80 |
$3K |
| D2331 |
|
45 |
27 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
24 |
$2K |
| D2332 |
|
23 |
12 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
15 |
13 |
$569.00 |