| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
251 |
145 |
$28K |
| D1110 |
Prophylaxis - adult |
438 |
437 |
$24K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
109 |
64 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
526 |
523 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
131 |
97 |
$12K |
| D1120 |
Prophylaxis - child |
166 |
165 |
$7K |
| D0274 |
Bitewings - four radiographic images |
171 |
171 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
55 |
39 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
131 |
131 |
$6K |
| D1206 |
Topical application of fluoride varnish |
326 |
326 |
$6K |
| D0330 |
Panoramic radiographic image |
73 |
73 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
190 |
188 |
$2K |
| D0272 |
Bitewings - two radiographic images |
63 |
63 |
$2K |
| D1330 |
|
330 |
330 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$1K |
| D0270 |
|
73 |
73 |
$961.60 |
| D0603 |
|
150 |
150 |
$840.00 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$430.00 |
| D1999 |
|
14 |
14 |
$0.00 |