| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
252 |
112 |
$45K |
| D1120 |
Prophylaxis - child |
360 |
360 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
92 |
40 |
$22K |
| D1206 |
Topical application of fluoride varnish |
390 |
390 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
205 |
205 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
12 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
257 |
254 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
98 |
98 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
275 |
227 |
$6K |
| D0272 |
Bitewings - two radiographic images |
125 |
125 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
15 |
$4K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$975.00 |