| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
625 |
292 |
$31K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
230 |
145 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
380 |
357 |
$11K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
168 |
78 |
$10K |
| D0330 |
Panoramic radiographic image |
287 |
273 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
232 |
129 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
200 |
75 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
232 |
225 |
$5K |
| D0274 |
Bitewings - four radiographic images |
280 |
265 |
$5K |
| D2335 |
|
23 |
14 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
94 |
88 |
$2K |
| D2332 |
|
18 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
353 |
328 |
$1K |
| D1351 |
Sealant - per tooth |
58 |
14 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
638 |
282 |
$503.83 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$476.19 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$166.05 |