| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
559 |
104 |
$28K |
| D1110 |
Prophylaxis - adult |
263 |
262 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
151 |
92 |
$8K |
| D0330 |
Panoramic radiographic image |
208 |
206 |
$7K |
| D0274 |
Bitewings - four radiographic images |
236 |
234 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
105 |
65 |
$6K |
| D1351 |
Sealant - per tooth |
222 |
30 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
263 |
263 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
187 |
184 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
99 |
99 |
$2K |
| D1120 |
Prophylaxis - child |
31 |
31 |
$900.00 |
| D0220 |
Intraoral - periapical first radiographic image |
118 |
114 |
$848.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
12 |
$104.00 |