| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,163 |
804 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,358 |
1,358 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
625 |
358 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
1,193 |
1,167 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
554 |
389 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
309 |
277 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
2,631 |
2,565 |
$6K |
| D0274 |
Bitewings - four radiographic images |
1,397 |
1,397 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
250 |
168 |
$5K |
| D1110 |
Prophylaxis - adult |
806 |
806 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
314 |
314 |
$4K |
| D1120 |
Prophylaxis - child |
497 |
497 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,684 |
1,798 |
$4K |
| D1206 |
Topical application of fluoride varnish |
872 |
872 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
737 |
737 |
$2K |
| D0330 |
Panoramic radiographic image |
690 |
690 |
$2K |
| D4342 |
|
261 |
130 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
427 |
427 |
$1K |
| D2394 |
|
61 |
53 |
$1K |
| D1351 |
Sealant - per tooth |
135 |
30 |
$1K |
| D2335 |
|
38 |
27 |
$904.00 |
| D4341 |
|
186 |
111 |
$900.00 |
| D0272 |
Bitewings - two radiographic images |
156 |
156 |
$700.00 |
| D0270 |
|
338 |
331 |
$572.00 |
| D0180 |
|
199 |
199 |
$546.00 |
| D0603 |
|
672 |
672 |
$465.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
26 |
25 |
$182.00 |
| D1330 |
|
2,404 |
2,059 |
$90.03 |
| D0601 |
|
28 |
28 |
$77.00 |
| D0191 |
|
76 |
76 |
$72.00 |
| D1320 |
|
115 |
115 |
$0.07 |
| D1310 |
|
1,005 |
1,005 |
$0.00 |
| D9986 |
|
1,477 |
1,392 |
$0.00 |