| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
828 |
500 |
$143K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
601 |
336 |
$83K |
| D1110 |
Prophylaxis - adult |
843 |
843 |
$56K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
581 |
581 |
$33K |
| D0330 |
Panoramic radiographic image |
611 |
611 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,005 |
1,005 |
$26K |
| D2750 |
|
40 |
31 |
$20K |
| D0274 |
Bitewings - four radiographic images |
768 |
768 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
575 |
575 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
249 |
245 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
944 |
925 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
72 |
36 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
634 |
632 |
$5K |
| D4341 |
|
29 |
12 |
$3K |
| D1120 |
Prophylaxis - child |
15 |
15 |
$733.50 |
| D1330 |
|
26 |
26 |
$187.20 |