| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
423 |
423 |
$17K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
101 |
31 |
$14K |
| D1206 |
Topical application of fluoride varnish |
381 |
381 |
$14K |
| D9420 |
|
58 |
52 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
432 |
432 |
$10K |
| D7240 |
Removal of impacted tooth - completely bony |
28 |
12 |
$8K |
| D1351 |
Sealant - per tooth |
244 |
91 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
74 |
26 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
81 |
61 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
51 |
$6K |
| D1110 |
Prophylaxis - adult |
94 |
94 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
137 |
137 |
$4K |
| D0272 |
Bitewings - two radiographic images |
147 |
147 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
76 |
76 |
$3K |
| D0274 |
Bitewings - four radiographic images |
77 |
77 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
58 |
58 |
$2K |
| D9920 |
|
15 |
15 |
$945.00 |
| D0220 |
Intraoral - periapical first radiographic image |
58 |
58 |
$835.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
18 |
18 |
$600.00 |
| D0240 |
|
14 |
14 |
$400.00 |