| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,296 |
4,296 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
4,862 |
4,862 |
$27K |
| D1206 |
Topical application of fluoride varnish |
2,305 |
2,305 |
$20K |
| D1110 |
Prophylaxis - adult |
1,381 |
1,381 |
$17K |
| D0330 |
Panoramic radiographic image |
1,034 |
1,034 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,195 |
3,195 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
384 |
292 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
465 |
354 |
$6K |
| D0272 |
Bitewings - two radiographic images |
1,575 |
1,575 |
$6K |
| D1351 |
Sealant - per tooth |
667 |
217 |
$5K |
| D0274 |
Bitewings - four radiographic images |
712 |
712 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
391 |
391 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
257 |
257 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
103 |
83 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
158 |
158 |
$821.10 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
15 |
12 |
$812.00 |
| D0220 |
Intraoral - periapical first radiographic image |
196 |
196 |
$692.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
16 |
$41.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
613 |
609 |
$0.00 |
| D9995 |
|
16 |
16 |
$0.00 |