| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,455 |
5,451 |
$241K |
| D1120 |
Prophylaxis - child |
5,995 |
5,987 |
$187K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,594 |
1,554 |
$172K |
| D0230 |
Intraoral - periapical each additional radiographic image |
32,577 |
5,928 |
$128K |
| D0274 |
Bitewings - four radiographic images |
3,880 |
3,878 |
$81K |
| D2160 |
|
918 |
674 |
$72K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,039 |
1,034 |
$62K |
| D1206 |
Topical application of fluoride varnish |
6,162 |
6,152 |
$53K |
| D2140 |
|
819 |
560 |
$44K |
| D1351 |
Sealant - per tooth |
1,238 |
282 |
$41K |
| D7140 |
Extraction, erupted tooth or exposed root |
671 |
400 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
430 |
273 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
521 |
519 |
$24K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
241 |
169 |
$19K |
| D0272 |
Bitewings - two radiographic images |
1,567 |
1,563 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
170 |
109 |
$9K |
| D9430 |
|
285 |
283 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
694 |
692 |
$8K |
| D1110 |
Prophylaxis - adult |
27 |
27 |
$2K |
| D2330 |
|
26 |
15 |
$2K |
| D2394 |
|
18 |
12 |
$2K |
| D2161 |
|
14 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$840.00 |