| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,872 |
3,872 |
$165K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,479 |
937 |
$115K |
| D1206 |
Topical application of fluoride varnish |
3,634 |
3,631 |
$109K |
| D0120 |
Periodic oral evaluation - established patient |
3,998 |
3,998 |
$108K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
777 |
375 |
$88K |
| D1351 |
Sealant - per tooth |
1,230 |
532 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
881 |
648 |
$44K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,328 |
1,198 |
$40K |
| D7140 |
Extraction, erupted tooth or exposed root |
811 |
459 |
$36K |
| D1110 |
Prophylaxis - adult |
508 |
508 |
$27K |
| D0272 |
Bitewings - two radiographic images |
1,387 |
1,387 |
$22K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
253 |
183 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
160 |
145 |
$16K |
| D0330 |
Panoramic radiographic image |
384 |
384 |
$14K |
| D0274 |
Bitewings - four radiographic images |
480 |
480 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
936 |
936 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
379 |
379 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
675 |
670 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
176 |
176 |
$5K |
| D1354 |
|
265 |
106 |
$4K |
| D2331 |
|
18 |
14 |
$1K |
| D9110 |
|
54 |
54 |
$1K |
| D9310 |
|
14 |
14 |
$1K |
| D9430 |
|
38 |
38 |
$779.00 |
| D0140 |
Limited oral evaluation - problem focused |
51 |
51 |
$714.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
71 |
71 |
$648.26 |