| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,174 |
1,284 |
$145K |
| D0120 |
Periodic oral evaluation - established patient |
3,124 |
3,123 |
$121K |
| D1120 |
Prophylaxis - child |
2,343 |
2,342 |
$95K |
| D1110 |
Prophylaxis - adult |
1,938 |
1,937 |
$77K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
967 |
679 |
$44K |
| D1206 |
Topical application of fluoride varnish |
2,362 |
2,362 |
$40K |
| D0274 |
Bitewings - four radiographic images |
1,504 |
1,504 |
$29K |
| D1351 |
Sealant - per tooth |
950 |
299 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,180 |
1,180 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
2,233 |
2,218 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
591 |
590 |
$19K |
| D0272 |
Bitewings - two radiographic images |
1,546 |
1,546 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
355 |
262 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
127 |
103 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
157 |
127 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
664 |
657 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,354 |
2,353 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
478 |
478 |
$5K |
| D0330 |
Panoramic radiographic image |
119 |
119 |
$3K |
| D9110 |
|
12 |
12 |
$210.40 |
| D0603 |
|
41 |
41 |
$0.00 |
| D1330 |
|
53 |
53 |
$0.00 |
| D1999 |
|
90 |
81 |
$0.00 |