| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
389 |
206 |
$15K |
| D1110 |
Prophylaxis - adult |
434 |
407 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
552 |
503 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
309 |
286 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
353 |
323 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
129 |
70 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
524 |
490 |
$3K |
| D1120 |
Prophylaxis - child |
106 |
95 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
133 |
129 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
298 |
232 |
$2K |
| D0274 |
Bitewings - four radiographic images |
120 |
116 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$834.18 |
| D1351 |
Sealant - per tooth |
53 |
14 |
$744.62 |
| D0140 |
Limited oral evaluation - problem focused |
38 |
38 |
$502.87 |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
12 |
$283.24 |