| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
226 |
123 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
529 |
527 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
137 |
37 |
$9K |
| D0330 |
Panoramic radiographic image |
156 |
154 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
298 |
295 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
78 |
54 |
$5K |
| D1110 |
Prophylaxis - adult |
124 |
124 |
$4K |
| D0272 |
Bitewings - two radiographic images |
262 |
259 |
$4K |
| D2332 |
|
53 |
29 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
67 |
43 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
30 |
25 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
196 |
186 |
$1K |
| D1351 |
Sealant - per tooth |
53 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
16 |
16 |
$480.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
21 |
21 |
$391.68 |