| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
955 |
951 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,274 |
1,270 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
429 |
376 |
$29K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
247 |
213 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
912 |
908 |
$25K |
| D2740 |
Crown - porcelain/ceramic |
57 |
51 |
$16K |
| D1110 |
Prophylaxis - adult |
330 |
330 |
$16K |
| D0274 |
Bitewings - four radiographic images |
802 |
799 |
$16K |
| D1351 |
Sealant - per tooth |
173 |
132 |
$13K |
| D0330 |
Panoramic radiographic image |
375 |
374 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
381 |
381 |
$10K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
59 |
44 |
$7K |
| D2950 |
|
74 |
70 |
$5K |
| D4341 |
|
19 |
14 |
$4K |
| D9110 |
|
68 |
65 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
539 |
535 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
375 |
373 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
51 |
$3K |
| D0272 |
Bitewings - two radiographic images |
246 |
245 |
$3K |
| D2332 |
|
20 |
14 |
$2K |
| D4342 |
|
16 |
12 |
$2K |
| D9630 |
|
12 |
12 |
$282.00 |