| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,741 |
686 |
$154K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,953 |
1,090 |
$117K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,165 |
374 |
$84K |
| D2335 |
|
535 |
188 |
$66K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
599 |
407 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
643 |
453 |
$24K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
274 |
229 |
$19K |
| D1120 |
Prophylaxis - child |
596 |
596 |
$19K |
| D1206 |
Topical application of fluoride varnish |
584 |
584 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
305 |
305 |
$6K |
| D1351 |
Sealant - per tooth |
132 |
52 |
$5K |
| D0330 |
Panoramic radiographic image |
177 |
177 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
206 |
206 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
153 |
153 |
$2K |
| D7111 |
|
66 |
53 |
$2K |
| D2332 |
|
13 |
12 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
15 |
15 |
$360.00 |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$206.58 |