| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,478 |
1,473 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,280 |
1,279 |
$30K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
577 |
568 |
$29K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
417 |
260 |
$27K |
| D7140 |
Extraction, erupted tooth or exposed root |
306 |
201 |
$23K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
214 |
151 |
$23K |
| D1351 |
Sealant - per tooth |
486 |
78 |
$13K |
| D1120 |
Prophylaxis - child |
367 |
367 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
97 |
81 |
$8K |
| D2140 |
|
142 |
118 |
$8K |
| D2160 |
|
94 |
69 |
$7K |
| D2335 |
|
61 |
42 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
119 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
69 |
69 |
$2K |
| D1330 |
|
246 |
246 |
$1K |
| D0603 |
|
76 |
76 |
$760.00 |
| D0272 |
Bitewings - two radiographic images |
44 |
44 |
$688.00 |
| D0601 |
|
50 |
50 |
$500.00 |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$490.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$473.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$392.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$96.00 |