| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
604 |
594 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
226 |
223 |
$22K |
| D1351 |
Sealant - per tooth |
413 |
123 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
135 |
69 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
102 |
49 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
755 |
742 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
45 |
27 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
191 |
174 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
78 |
43 |
$4K |
| D1120 |
Prophylaxis - child |
775 |
761 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
14 |
$871.85 |
| D0230 |
Intraoral - periapical each additional radiographic image |
939 |
685 |
$842.19 |
| D0272 |
Bitewings - two radiographic images |
300 |
294 |
$522.79 |
| D1208 |
Topical application of fluoride, excluding varnish |
595 |
585 |
$245.01 |
| D1330 |
|
862 |
848 |
$141.23 |
| D1110 |
Prophylaxis - adult |
32 |
31 |
$42.00 |
| D0274 |
Bitewings - four radiographic images |
64 |
64 |
$5.00 |
| D0330 |
Panoramic radiographic image |
30 |
30 |
$0.00 |
| D1999 |
|
278 |
270 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
278 |
274 |
$0.00 |