| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
661 |
661 |
$44K |
| D2750 |
|
79 |
54 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
238 |
157 |
$33K |
| D7140 |
Extraction, erupted tooth or exposed root |
188 |
92 |
$25K |
| D1206 |
Topical application of fluoride varnish |
764 |
764 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
97 |
69 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
500 |
500 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
233 |
233 |
$13K |
| D0330 |
Panoramic radiographic image |
278 |
278 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
108 |
83 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
230 |
224 |
$11K |
| D0274 |
Bitewings - four radiographic images |
414 |
414 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
812 |
780 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
562 |
559 |
$5K |
| D2950 |
|
53 |
38 |
$5K |
| D1120 |
Prophylaxis - child |
32 |
32 |
$2K |
| D1330 |
|
14 |
14 |
$100.80 |